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07/11/00 TGE 10:33 FAX 1 91 1 0430 SECOF.,-SACRA IIENTO Z002 <br /> FROM : West Hazmat FAX NO.' : 19166369613 • Jul. 11 2000 07:44AM P2 <br /> 07110100 HON 16:58 FAX 1 918 861 0430 SECOR-SACRARENTO ¢101a <br /> 6h/2E/200e 09:23 2094683433 1 rr rH F1 nm PAGE 04 <br /> Icaticlr tY , 10rlianC'^' . <br /> $anJoquinG,o.4!I�r;tnvirpntnentalHoaRrt K®s,LfpklY� YVgt�e"'mI,Y:1�pp � <br /> �'.Qsgssl 235�e5sa�►� ad.d P�'R�n�r s X23 _ <br /> .. '„I)QAl ?.•'' `_ " '2 y,9-D7o•=bip�- a3"i§g 5 2u»4cfd <br /> • . -. 249-07U-ocg 13G6s'9'x,w4Fc' <br /> 249'D1.6-or2 is7olSsw4f:: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm tint I nm licensed under the previsions of Chapter 0(Commencing with Seton 7000)of Division <br /> 9 of the business and Professions Code and my liranao is In full forces and affect. <br /> License 4:—sAa a g 7 r 7-.- Exprretlon Oita:�.'_33/ O <br /> Data: -1 - 1 U- 00 Conbaetor: Wes�- F a _ a-. ��a\;. y fs rpav"rnL. - <br /> signature+. � Tom: T"rO'/'ri — <br /> printed na �-gr��, <br /> CCC WORKERS' COMPENSATION MCI ARATION <br /> I hereby affirm under penalty of perjury one of the fnliowing didarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a Certificate of consent to self-insure kir workela'compensation,as provided for by <br /> Section 3700 of the Labor Code.for the performance of the wort for which this permit is issued. <br /> have and will malntain worker:'compeneatlon ineurunce.as required by Section 3700 of the Labor Code, <br /> for the performance of the work forwhiaii Ode permit id famed, My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Certify that In the performance of the work for which this permit is is8ued, 1 shoo not employ any person in <br /> any manner Be as to become subject to the workers'compensation laws of COKOWa, and agree that It I <br /> should heiome subject to the workers'Cnmpansation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those previsions. <br /> Uate: 0 V signature: K�_� <br /> Printed Name_ ctf7isr q ✓�'_'-.. /"' °� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANU SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PP..NALTIES AND CML FINES UP TO ONE HUNDAND THOUSAND DOLLARS <br /> (=100,060.),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,ANU DAMAGES AS <br /> pRMUE0 FOR IN SECYION 3708 OF THE LABOR CO <br /> I (C-67 licensed authorised represents"),hereby I <br /> LA'i✓tr /4UCN-Ti.7� f C6C'Y�_ <br /> n Joaquin County Well Permit Application on my behalf. I understand diia ouemniation ib valid for <br /> d,is IiMtead rgthe work Ptan dated on thecae of this aPPlicadon., <br />