Laserfiche WebLink
07/11/00 TLE 10:35 FAX 1 916AM 0430 SECOR-SACRAMENTO • Z003 <br /> 7-11-210 7.21AM FRCh SCH ENVIRONMENTAI. 2097723S71 <br /> P. 1 <br /> Uu 1U:UU $UN 16:45 !M 1 H16 bbl. U49U 5hl'JH-SdCkeU!!;N'lU <br /> M'22/28@8 88:23 2894683433 FIFTH FLODp 10 01U <br /> PAGE 04 <br /> Sant m:CtJo Ehrtrenmenlal N® <br /> MY: - at)1fSenneefCiU�ut.Rt•MYhkPeent�i( featantt <br /> Sgpplilment <br /> 711aB/iE$]E2E:55 Z3�`f .S�.ia !c Zok F'ERlKkT � <br /> f <br /> UCENISED CONTRACTORS DECLARATION LCOS <br /> I.hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of Ne Busineaa and Professions Code and my license is in full force and effect. <br /> License#: G638G,5 Expiration Date: la•.3l-0�2 <br /> Date_ 7-10-00 Contractor: (• 54� EtiV�o.��nen�1 �.}In)nra�TA� Su.vrt�,r - , <br /> Title: "Ne[ <br /> Punted name: .7)AJi D F1 S6ti{ <br /> WORKERS'COMPENSATION DECt RATION <br /> j 1 hereby affirm under penalty of perjury one of the fdtowing dedaations: (CHECK ALL YNAT APPLY) <br /> _ i have and vh0 maintain a certificate of conscrit to self-insure for workers'compensation, W provided for by <br /> SSecffoi 3700 of the Labor Code, for the performance of the wort[fotwhich this Perrtet iS MUed. <br /> ✓1 have and Will maintain worker;compenSaton insurance,as required by Section 3700 of the Labor Code, <br /> for the.perfortnsnce of the work for which this permit is issued. My vArkers'compensation msunance <br /> Carrier and pofcy number:MS <br /> Carrier: .._4-L (1009117 Policy Number: <br /> _I certify dont M Ne perfiormarice of the work for which this permit is ttsued. I shad rwt employ any person in <br /> any manner so es to become subject to the workers'c0mpeneatMn laws of California,and 2*ree that it I <br /> shoWd become subject to Site workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> "wiQl compy with those protreions. <br /> If Date: 7-/o •D4 signature: <br /> Pritfted Nama: ✓/q•✓/ D ry6[a1 <br /> ` WARNING: FAILURE TO SECURE WORKS"'C0W04SATION COVERAGE IS UNLAWFUL,AND SHALLSUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED T14OUSANO DOLLARS <br /> (5100,000.),IN ADMON TO THE COST OF coUPMATION.INTEREST.ATTORNEYS FEES,AND DAMAOES AS <br /> ` pReMoeo FOR IN SECTION sM or THE LABOR CODE. <br /> /f1.3G74 (4s7licensed authorized represettmtlYe),hwxft <br /> author <br /> to sign Ihm San Jmgwn CoUrIV WNI Permit APPII6 ffert on my behalf. I urdrisand dds attthprlatim is rand for <br /> aro 1 ssr and is Ilmtad to the work plan dated on the front gaga of this appliotiam <br />