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FROM West Hazmat FAX NO. 19166389613 May. 19 2000 11:07AN P1 <br />05/i9/2000 11:36 2094671118 AGE 5TCICKTON PAGE: 04 <br />-.PEE X -T SRW: <br />j <br />JOBADDFMSS" <br />YAA. <br />§pDdCONTRACTORS DECLARATION (LCD) <br />I hE reby affirm that I JgK un er 11�6 provisions of Chapter 9 (commencing with Section 7000 of Divisic in <br />3 othe Business and Professions Code) and my I . n 8�,,rpjull rce <br />S tetijon.7000 of Division <br />I hereby affirm that Varn khnsed under the PrOiWsIrns 01 r <br />Lic160f;%bfi Busl ±$$ And Professions Code) and myfr�Tl��e"*':L <br />at Expiration Dale' 2-4044 <br />if.9 Contractor. <br />i g I po pi I ---T"it ee- <br />ri <br />Printed name: <br />WORKERS' COMPENSATION DEC <br />WORKERS "COMPENS. - - - - C <br />I he eby affirm under penalty of periury one of the followiD�dglaralions: <br />t <br />I hereby affirm under penalty of perjury one of the fOlIDWIf 9 i�oara ions: <br />I have and will maintain a certificate of consent°NBA <br />,fg Y <br />f <br />4V9,-,.ri�aFF <br />Section 3700 of the Lo <br />ave <br />6de, for pe <br />in a)*n v,,orkgrk'hQmoer4SnaA1kRf r82g08fcjfi61mbsibe00�di <br />I ve and will m. t &A rr" U f @6 14 <br />Mill' W .11 <br />De pr 0 Xiwo <br />.4• arrie 0 %S&je* <br />• ciii-rier are'. <br />C LJ4 Z-7 <br />va P _19 2- <br />irri <br />C <br />R' YO <br />nia i t <br />6mkaag e) fil <br />111"ViPeRalsor ode, s a <br />e <br />orihvib�tGKitlmlchhvHitbdbg5�pri�'1't&��.ns ,q <br />"-?&r�P69Y0 �,Y� <br />Date Date: 06---114;15RW. <br />Et , a <br />P r 1 A 08IFA h�%T e: A —M -L <br />COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL. SUBJECT <br />WAR q SUBJEC'' <br />ANE AS <br />(SID INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PRO 1 11 N 3706 OF THE OR CODE. <br />A, (e -5T license holder), hereby <br />• A E. I for— P-1 d <br />authorize C: Of Sal <br />iaiiqujn County Well Ferinil APINKOW'"" <br />io',aqjin County Well Permit Ag, icg <br />11 Fno is valid for one (1) year. <br />and is limited to thit work p an OR <br />and is appricaUon. <br />oweliar <br />