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U1/11/00 TIE 10:33 FAX 1 91 <br /> FROM : West Hazmat 0430 SECOR-SACRA.IIE\TO <br /> OFAX NO. 19166388613 a002 <br /> 0G/2E/2880 888:23 10/00 LION !23 SECOR-SACRAtfENTO FAX 1 91e Bel 0430 Jul. 11 2000 07:44AM P2 <br /> ., <br /> 2894663433 1 rr rH FT rM [J 014 <br /> PAGE 04 <br /> FLr1,JoigninGo.Wn�r:Env1— -ro WINaaRn rvites.l!)►hllf,WgtiPonNitl q _lea'lib�{a,� <br /> .gbS/��p1�ss123 blo5 S.Saw.1-h;Fa. Ro.d.. r �At .. <br /> L;L <br /> LICENSED CONTRACTORS DECLARATICON LCD)237615c,"6`� <br /> I hereby affirm that I am licensed under the provisions of Chapter D(eommencinn with Section 7000)of Division <br /> 3 Of the Business and Pmfossions Code and my license is In full fonw unit effect. <br /> License 419 7 ExpGadon Date: O <br /> Date: - 1113 fib CUntactor: , _ <br /> Signaturer-- _ Title: �R"I`4 <br /> ✓fL ......... . <br /> Printed natpa <br /> C WORKERS' COMPENSATION DECLARATION y - <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to Half-figure for workers'compensatlon, as provided for by <br /> Section 3700 of the Labor Code. for the performance of the worts for which this permit is issued. <br /> ave and will maintain workers'compenaatlon insurunce.as required by Section 3700 of the Labor Code. <br /> for the perfornance of the work forwhictt drie permit is laeued, My workul5'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier:� Policy Number:..-?�`fib/LJb ErLCLL6eo <br /> Certify that In the performance of the work for which this permit is i54uad, I shell not employ any person In <br /> any manner no as to became subject to the workers'compensation laws of California, and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shell <br /> forthwith comply with tllose provicons. <br /> Date: 6 :4- Signature: <br /> PrtMed Nemo: r ufr s �/r /'r a <br /> WARNING:FAILURE TO SECURE WORKliiKS'COMPENSATION COVERAGE IS UNLAWFUL,ANU SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PP..NALTIES AND CML FINES UP TO ONE HUNnI THOUSAND DOLLARS <br /> (5100,000-),IN ADDITION TO THE COST OF COMPENSATION-INTEREST,ATTORNEYS PEES,AND DAMAGES AS <br /> PROODED FOR IN SECTION 7708 OF THE LABOR CO _ <br /> I, .- r (a-61 licensed authorised luprsasntattve),hereby <br /> a orf:o �A' Ae6�'Y.yLZ <br /> to sign II Ban Joaquin Coin Well Permit Application on my behalf. I undaratand this authoniation io valid for <br /> are 1) ear and.I;I(tnhad m the workplan doted on the front page of this applicavom <br />