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FROM : West Hazmat FAX NO. : 191663BB613 Apr. 20 2000 02:OOPM P3 <br />04/20/00 THU 11.15 FAX 916 3 .889 SECOR-SACRAMENTO I&003 <br />84/14/2000 12:25 2894663422 FIFTH FLOOR PAGE 84 <br />Saalgi�,Illi'�A�,y�[tYlConRl6AbtiiCalthS�t�►ICpp;l'Id1Ft]f�A/qil'Prb6htlt�JiPbf1�}lionl;SupR�fp¢t�t , <br />� 'ia�R431ti <br />LICENSED CONTRACTORS DECLARATION (Lc'D) <br />I hereby affirm that i am licensed under the proaisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Businesa and Professions Code and my license le In fwjI force and affect, <br />Licenea #' 5 5 �� �— Expiration Date: _ - i - Z o o <br />IOem- "I " z� �?_ 46ontfactor. k iE 5T_ HA Z M AT" .D t L L i 1�C-, CSR <br />signature: <br />Printed name: <br />Title: <br />WORKERS' COMPENSATION DECLARATION <br />I heroby Arm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will malntaln a CertlRcate of consent to calf -insure for workers' compemsa6orl, as provided for by <br />2'-ction 3700 of the Labor Code, for tho p®tformance of the work for which this permlt Is issued. <br />1have end will maintain workers' compensation insurance, to required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is isatled. My worker' compensation insurrance <br />Carrier and policy numbers are: <br />PolltY Number, Pv R E U Q <br />g 8 114 5& Z 600 <br />Carrierl <br />_ I certify that In the performance of the work for which this permit is issued. I shall not employ any parson in <br />any manner so as to become subject to the workers' compensation taws of California, and agree that if I <br />should bawme subject to the workers' compensation provisions of Section 37DO of the Labor Code, I shall <br />forthwith comply with those provisions. <br />pate: <br />+-/ �.2-0lOQSignature: ` <br />Priinted Name: <br />AN EMPLOYER TO CRfMINAL CN4L7'iEs AND E KE UP TTION o aNE HUNDREl7 THOUSAND DOLLARS <br />GE 15 UNLAWFUL, AND 8HALI_ UB.I�CT <br />PROVIDED FOR 3749 or` THELA-1-0 THE COST BOR ODEON. INTERFST, ATTORNEY'S FRIJS, AND DA"11329 AS <br />OR IN $ <br />licenesd authortnd representative), horOY <br />to sign this San Joaquin County Wall PannIt Application an my belU+r- t understand thts authorizatlon it valid for <br />and is limited to the work ;un dated on the "_ of this a <br />