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07/11/00 TUE 10:35 FAX 1919OL61 0430 SECOR-SACRAMENTO z 003 <br /> 7-11-200 7:21AM FRI ISCH ENVIRONMENTAL 2097723571• P. I <br /> QI/IWUU AUN 16545 k" l 1116 b 1 U43U 5YC'UH-9ACIUftN'111 I�010 <br /> 86128/2988 118:23 20W03433 FIFTH FLOOR PAGE 04 <br /> n-1�Na ,EnvYVempenlRl'Fiw1�hS�rniee0i Pandlrl9 apt <br /> Uhl <br /> RP1A 2qq=070-o1Z 23U4s.:s.hFt irrk <br /> 2`t4'A7D- Olo 23is4 S Isw1P. tc Rarw� <br /> LICENSED CONTRACTORS DECLARAMN LL CD) <br /> mansby'afirm that I am licensed underthe provisions of Chapter 9(commencing with Section T000)of Division <br /> 3dtthe Susiness and Profeaaiorla Code and my license is in full Nom and reflect. <br /> License 0: Expiration Date:/Vy51-dal <br /> am 7-10-00 Contractor trsc`L�Qw.ri.r..rnehl+.t £Rol,�a�. Swvrr4,r <br /> raw r_/v __T•itle: . "Af a g. <br /> Punted name: '))At/r D 11'-1504 <br /> WORKERS'COMPENSATION VE"RATION <br /> I hereby affirm under penalty of perjury one al the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and YAP maintain a eeMcate of consent to self-insure for work*rs'wmpensation- as provided for by <br /> Section 3700 of the Labor Core, for the perfenn0 roe of the work forwhich this permit is(s5uad- <br /> ✓1 have and Val rna*ain worker compensation insurance,a3 required by Section 3700 of the Labor Code, <br /> for the,performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and pot-icy numbers ate: <br /> I <br /> Carrier: YY) Policy Nuhtbel; i5.3/Ac145--9 g <br /> _I certify that In tie pe610rm21`10e of the work for which this permit Is Issued, i shad not employ any person in <br /> any manner so as to became subject to the workers'cornpens;;Wn laws of California,and agree that it I <br /> shoWd became subject to the workers'cornpensadon provisions of Section 3700 of the Labor Code, I shall <br /> ft vAel comply with those promons. i <br /> Date: _„__Signawm;— <br /> Printad Name / D SGa.0 <br /> WARNING:FAILURE TO SECURE WOMMS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER To CW NINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO TWE COV OF COMPENSATION,INTEREST-ATTORNEY'S FEES,AND DAMAGES AS <br /> i PROVIDED FOR IN SECTIONa7p6 OF THE LABOR CODE. <br /> I <br /> (CS7Neensedauthorisedmeprsser>mdve),hereby <br /> i <br /> 7 authatrae <br /> 1 to Olen mie.sin Joaquha County Well Permit ApFlleaaen on my behalf. i uw.&s t rid this at21rorlza0a is valid fOr <br /> i ane(1)7Oar and is IimhOd-to the Work Pan dated on the front pa"of this applicatko <br /> i <br /> I <br />