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__ll/U51VU RUN 14:5U_FAX 916 858 0605 <br /> IT Corporation/RC 1 003 <br /> FROM" ; West Hazmat FAX N]. 191653@8 13 ( �. @@ 1999 10:29AN1 P2 <br /> _ il/08lsq f Flt_i 10.35 FAX 816 858 04103 IT Corpor riou/RC �Qp= <br /> Bari Job dirt Cotttri i V61rbintnert�l7 atth�8 `fVi�e1fDRSIQplMivfe f+ mam <br /> JOB MERESTX: I PE"M, <br /> . i <br /> LICENSED CONTRACTORS DE LAPATION (LCO) <br /> I tseraby etlim,that l tusl lioansad under fihr prOviaior s of Ch"Mr 9(MMMending with Section noo)of mvlslon <br /> 3 of ft GLmirt0ii arid P►of &10frs Code and my i cense Ia In fuii forcg and,eflisot <br /> Ucence V. .M 77 9Exp�on ! •?.po7 <br /> Date- 10 r-9'r Cantractor.. &G=dt&zAT-' ,r<.�,...,e ► <br /> Slgtnatu c: P-v C>146r. <br /> Printed rtat�' <br /> WORKERS'COMPOMY1ON McLAUTION <br /> I hereby affirm under penaity of penury one of the folk wing dwisr Itionw. (CHECK ALL THAT APPY) ' <br /> r„^1 end WIN tnMMMI t a oertifidi de of dant to self-insure Ir wdrkew cgmpM ftL as provided fpr by <br /> action 3700 of the Labor Code,for the perfarrrtan=of the for which thisnn <br /> Pei(Is i"uW. <br /> ! neve and will maintain workers'twmptentaLon i�urance, ■6 quired by Secfbn 3700 of Me Lxboe Code <br /> , <br /> Tot the performance of the work for which this parry*ie iuufrd. ray worfrar6'componsatlon insurance <br /> C~Cand policy numbers era: <br /> Carrier. rt� Policy Ntaw <br /> I Q8"that in the peckme11d1 of the work ffor which this pe is sued, I"annot empiay any person In <br /> any manner 6o as to become sub]at to ft+corkers'comperrs tion laws of Cetlfamia.and agree that If I ' <br /> MOM becorrre asubjeat to the eek*'cvmprrlsa*m prthrit3 s of-Section 3700 of the Labor CWC I$hoN <br /> fbnhwith comply with thm a pnmwmm, <br /> Date: <br /> PAnWd lime: <br /> WARNMW.FAILURE TO SECsu1RE woMEEfAtt3'C0YPIEN5A-n*N Gtr IS U14LAVWU1,AND SMALL SUBJECT ! <br /> Mit eMPLOYER TO CRIMINAL,PEMALTES AMD CMI.AHEB UP TO a WE HUxj)RgV YHDUSAND DOLLARS <br /> (5190.410o.l,IN AD13MON TO TIR COST OP COMPSMAMON.MTEAR 91T.ATTORNEY'S PEES,ANC OA1It&G A AR <br /> PRMCMP FOR IN 8ECTION 3706 OF THE LABOR COd1E <br /> L (C-467 'cemgd•4oftr"mvd►aPhwenMV6 j,havgby <br /> ev sign thle Sets.ro"mia County Will p&nu E AppUg"Ga on my M", i un00retant,egg aiatwrlr tkM i6 via[w[ot. <br /> ane 1Per and in lirnftd to tlr"mk dated on Ow front few of <br /> 1 <br />