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,9-23-1999 10 : 03AM 1 FR01`•1 F I SCH EtA v I RONM CENTAL 2097720571 <br />eep-22-99 11:34 APEX IVIROTECH.,INC. 91553 :07 <br />10 9-22-1999 9 : 27AI 1 FPL <br />JOB AaoREss,�1 `1L�1,L�L.�." N PERMl7# <br />P.02 <br />� J <br />LICENSED C014TRACTORS DECLARATION <br />I here Dy affirm Gnat 1 arm 11CemSM unf@r tlhe pr Svtsions of Chapter 9 (c omrnencng wIL`t Section 7000 of Civision j <br />3 of the auv^ess and PtnfessQns Code. and my license is in tun force and effect i <br />Expira�on Dau <br />elate `�Z� �'7 ntr:nCOr''SeH �tidlf4�'ac�✓1�}L <br />Signature <br />WORKERS' GOMPIENSATiON DECLARATION <br />I hereby affirm uRdtr penalty Of Perjury One O'` tfse fCdbwing decalaradons= <br />Lj I ?save anct wit, rts3imairt a Certificate of corrsent fD selt4nsum for vvork9rs" compwsadon. as proved fpr by <br />I Secton 3700 or the tabor Code, far EW pc•fforrnance of the wont for whin ENS pert'ut is issved. <br />O ; have 3no wib maintain wOrkeFV WmPen5addn insurance- as required by Secttcn 3700 of tree Latoer Cane. <br />.or the pertcrsnarste of the work tV �whicn IMUS Ptmll is issued. My worKefs, mfnPertsatian insurance Cartier <br />and panty numCet art: <br />1` r <br />L , <br />l <br />CEMOf_J L Po6Cy Numt>K, <br />j O 1 mm,fy that Moe oet afn ante of"wark For which Osis p*Md is LUU41 . I shwa no! MMIOy any person in any marrow <br />so as to ae=me subisa to"workers' eel itp(MaWm laws of California. wo agnw &wt if i Should bee"16 suniect to <br />;ne workers CpmPensairOn provia:ons of Sactitn 3740 of ale :doer COCA. I shall :ortnrdts COM Y wlh tfwse Omvisdons. <br />1 <br />Cate _ Applicant <br />i <br />} W^RNING; FAILURE TO SECURE)NORKERS' :�O4IPENSATION COVERAGE 15 UNLAWFUL_ ANO SHALL 5U8JECT <br />AN EMPLOYER TO CRIMINAL PCNALTIES AND CMC, FINES MIP TO ONE HUNDRED THOUSAUD 00U."S <br />(100,000), iN ACDITION tb THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTiQN 3706 OF <br />rWrm LABOR COLE, INTMEST, AND ATTARMf,'1" S FEE`S. <br />