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FROM : West Hazmat FAX NO. : 19166388613 Feb. 19 2002 12:37PM P-' <br />FEB 19 '02 12:22 FROM: <br />02./1 i/2002 @8: 1y `)094b81131 <br />TFTH f i [SUR <br />�.,,; �-•-�--rte.-.,• ,r�-r. <br />LICENSED CCNTRACTORS DECLAMATION LC ) <br />T-229 P 02/02 F-128 <br />PAQ- 01 <br />I hereby affirm that I am licensed under tea provisions of Chapter 8 (commencing with S"O ion 7000) of Divisior <br />3 Of the Dusiriess and ProfftaIons Code and mY llcen46 is In full farce and efterct, <br />License #: - <br />^E�cpiradOn pate: 01-31- d <br />Data: D Z - / 5;-d 2 Contracta 1` - /-/4 z/ -ate <br />signet" <br />�,, Title: 02 <br />print d nC"'e: <br />WORKERS, G()MPEINSATION DECLARATION ` <br />I hereby affirm under penalty of perjury, onQ of the fallowing dOcl$rations: (CHECK ALL THAT APPLY) <br />have and w111 maintain a crrtlficatr~ of ron3ent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor God(,. for the perft.rmarjce of the work for which this parmit is issued, <br />havfor <br />and will Maintain workers' compenaatiG1 insurance, as r+equlrnd by suction 3'/00 of the <br />far the parfarmance of the work for which this : armit is issued, My workars''QOmpensabon insuranceCpde, <br />carrier and PO icy numbers are: <br />Carrier: <br />Policy Number:.�2. + 7 ✓e 2- ! _ <br />--e- Ic8r* that in thea performance of the work for w;'-ich t <br />any manner so as to become subject to the warki_ '6' ro�mpe sat mit isnaw of shall not <br />as and agree that It <br />p Y y person in <br />should becOt PI subject s the visions. comper�se;,,aR provisions Of Section 3700 Of thelabor-Code, I shall <br />forthwith dorrrrply with those provisions. _ <br />Date: 4 - 1-a 'L- <br />---7 <br />Signal <br />Printed NaM. A <br />WARNING: FAII_URk 1U 6bc[1fCfr WQRkkR6' CGrMPENiTIGN CUVERAaE 14 tIp1LAWfU�, <br />AN LMPLOYER TO CRIMINAL PENALTIEN AND CIVIL FINES UP TO ONE "UNbREb T"OU'SAAND Np DO"IRSUeJECT <br />($100,000.}, IN ADPITION rO THie COSY OF CoMftNSATION, INTEAEST, ATTORNI;W6 FLEE, AND DAMAOrrti A8 <br />PROVIVED FOR IN SECTION 3706 OF THE LABOR Coop <br />(C-57 hennaed nuthortzod repmg0rit0tiv4), hereby <br />elutharhta <br />to sign this stun Joaquin County VYoI! P's:rmft A <br />ppilexhon on mY b6Uf. I unday6tand this slutharizgtion In valid for <br />ono impar rind Ia Flmlted tothe, work pian the front�a of this a Ilcntian. <br />u <br />