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07/11/00 TUE 10:35 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />7-11-202 7 : 21AM FROM F I SCH ENVIRONMENTAL 2297723571 <br />Vi/IVULJ KOIN 14:4S IAA .1 blb 1141 U430 b LC UR - SALRAMENTU <br />ea/28/2e8tt 013:23 2014683433 FIFTH FLOOR <br />ZOO <br />P. 1 <br />Oulu <br />PAGE 04 <br />Stiri:JOMOIWCtiarityi Environntentelliteafth Serviees, Unit: :44N!Mkperi.e:itA <br />A(,) zi-vt o-to- t 2_ <br />ut - 07G)- 0 to -2.3 4. S 1 Cc 344 <br />LICENSED CONTRACTORS DECLARATION (LCE2) <br />hereby affirm that t am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />a of the Business and Professions Code and my license is in full force and effect. <br />License 0: 4 3$4,5 Expiration Date: _A?? -13/- O2. <br />Date_ '7-10 - *0 Contractor: <br />Signature: Title: &A),/if-y„, <br />Printed name: <br />WORKERS COMPENSATION DECLARATION <br />! hereby afilrrn under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and v411 maintain a certificate of consent to self-insure for vit/fkOrS* compensation. as provided for by <br />Section 3700 of the Labor Code, for Me performance a the work for which this permit is issued. <br />/have and Will maintain worirer5' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensatiori insurance <br />carrier and porroy numbers ars: <br />Carrier: ..1-1--d4- (pirnio <br />certify that in the performance of the work for which this permit is issued. shall not employ any person in <br />any manner so as to become subject to the workers' cOmpensation laws of California, anti agree timid i <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />fetthwitt comply with those provisions. <br />Date: 710 Signature: <br /> <br />Printed Name: J3t&D <br />WARNMG: FAILURE TO SECURE woongs) COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT <br />AN EMPLOYER TO craMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />IN ADDITION To THE caST OF COMPENSATION, INTE/tEsT, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDEDFOR IN SECTION MS OF THE LABOR CODE. <br />h_ -D410 6r.51Gt4 (C-ST licensed authorized representative), hereby <br />authorize , S.Prelif <br />Policy NuMber: )6.3 6 c24-5 9 <br />-J <br />to sign Ibis Sari Josqulo Count/ We41 Perrnit Application on my behalf. I terearrstand thls authOtization is valid for <br />one (1) your and is lirnierd,to the woritylarn dated on Ina front page of this appficabort.