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07/11/00 TUE 10:33 FAX 1 9160430 SECOR-SACRAMENTO f>1j. 002 <br /> FROM : West Hazmat 0 FRX NO. , : 19166380613 9Jul. 11 2000 07:44AM P2 <br /> 07/10/00 MON 16:58 FAX 1 918 881 0430 SECOR-SACRAMENTO 2014 <br /> 04/28/2099 88!23 2894683433 1 rFrH FL nm PAGE 04 <br /> t;air- Jp�'�gn1n CMoWp�liEnvironmerNalH9aRrt iees,1f11h nf;Wtlt rperq;N,� q -ieaMiii►r� kM IOMiRiC <br /> l= <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby ahem that I nm Ii06rl6ad under the provisions of Chapter 8(commencinia with Section 7000)of Division <br /> 3 of the Business slid Professions Code and my lic anss is In tug form and affect. <br /> License a: 5 4 Expiration Oate: <br /> oats'. - 10- 00 Contractor; I,wes� <br /> signat5rra ! r Title: Zt%,f aJAt 1i'IiY►Mbb"' _ <br /> Printed na ra/+ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dodarallons: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workela'compensation, as provided for by <br /> section 3700 of the Labor Code.for the performance of the work for which this permit is issued. i <br /> ave and will maintain workers'compensation insurance.as required by$action 3700 of the Labor Code, <br /> for the perfommnce of the work forwhidl pile permit is issued, My workais'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 1* Policy Number:__P�`/brLJsS�rGfLz-6so _ <br /> certify that In the performance of the work for which this permit is issued, I @hall not employ any person In <br /> arty manner so as to become subject to the v,,rkaml compensation law.of California, and agree that If I <br /> should hecorrw subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shell <br /> forthwith comply with those provisions- _ <br /> Dater, j2 /l-LO Signat4re: <br /> Printed Nana: <br /> WARNING: FAILURE TO sECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,ANL]SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL peNALTIEB AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION To THE COST OF COMPEN8ATION,INTEREST,ATTORNEY'$FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 Of THE LABOR CO <br /> l r (O-51 licensed authorized r@presentasve).hereby <br /> e ods@ <br /> ^uas�7'L7� s' (se-c�_ <br /> .! 1'ir /'r .,..-..._ _. .....,. <br /> to sign 9110 San Joaquin County We11 permit Application on my behalf. 1 understand this su9ronzation is valid for <br /> ane 1) Sar and,ls lirnaad <br /> tate workPlan dated on Bw ffaet page of this a1ica9on._ ,_ <br />