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%11-18-1999 5:23PM FROM FISCH ENVIRONMENTAL 2097723571 F <br /> i San vJ�rqutn Courtly Env"Jilr TrialH�wtt Services,unit 1'v +1l.Prem#k.iAp afi�atioit Snpplairwnt <br /> iQ8 ApmEss. . 5-6(A3 1`I•kf- Si, , <br /> r <br /> LICENSED CONTRACTORS DECLARATION ON (LCQ <br /> C !tweby affirm that I arcs lloonsed vrider.the proVisl)ns of Chapter 9(cCitXrrrlenoirtg with Section 7000)of Mvislon <br /> 3 Of the B"M"and Profusion <br /> ns Cade•acid my license is in fuii force E 0d,effW, <br /> License#: [U� _.. ,Expirgtion gate:_ 1 _ i- a <br /> C1ste: iLY ,.t q/rj Ccmtra tor._ P 1`c" t- <br /> Title: 01,_3N e t� <br /> Prinbd na#na: <br /> WORKSPB'COMPENSAMN DECLARATION <br /> 1 hereby 6rHirrxl under penalty.of p&dury urte ofthe fdlowing declarat io ns: (CHECK ALL'f AT APPLY) <br /> h8w&and will nuintain a oesrtificata:o f consent to self insure for workers' <br /> Seetitvl 3700 of ft Labor Code,for the aarnpensabon.as provided for by <br /> perforn�nce of the araric ftrrwhic�this permit is issued. <br /> -V!have Orr MN maitrtain workers'.con <br /> '>1Hnssatiorr iri5urarsce,acs required by Section 370+7 pf the Labor Codec, <br /> i for this performance of tate work fbr+orhicb this Wrnit is.itsued. My workers'cai <br /> carrier and ooi Oy nwrtbers 2mpens<,ttion <br /> re: insurance ! <br /> 7? Carrie "S - -- --- - Polcy -^ <br /> t <br /> 1M <br /> rLYy than in the pettormarrce of the work for which(tris parrrilt is issued, !shall.i'sot employ any n in , <br /> a any manner so as to became$ubiw:to the worker*carrip@i'aaeon lows of Catifortria, and agree that if! I <br /> should became subject to the woi'ktnr compensation provisions et se6tion 3700 of the Labor Coda, I shall <br /> farttrwith comply with those p(ovistank. <br /> Berlet: 81gMitura: L J <br /> Printed Mine. -- <br /> WARNING:FAI4URir TO SECURE WORKIER3"CCWEMATiON COVERAGe#S UNLAWFUL,AND$HALL 846JECT <br /> i AN RNPLOYER TO CRIMINAL PENALTIen AND CIVIL FINER t!P TO ONE MUNC ttED THOU"} DOLLARS <br /> 04004= ,IN ACXX'nG H TO TF#E COCOWCl''COMPENSATION,INTEREST,ATTORNEY'S Fii$,AND CaA1MAt?ES AS <br /> PItGVIQEi�1 FOR IN SECiYC?N.3704 OF THER CODE <br /> MoMterat *4#e).homby <br /> ' to sign this F.ewr,.foacluiri, <br /> C�uft Wali ftrirlt Avptieadoe an my bNlaiif. r aindors#and thio aui'#ioftMtj0n is vettttJ for <br /> !one(t?year and is#im#iwt# ►ttMe 1Mrorlt.RFan d oro Wo FWWA Palms Of th* #Iotr"n. <br />