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07/11/60 TUE 1035 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />7-11-222 7:21AM FROM FISCH ENVIRONMENTAL 2297723'S71 <br />Vi/lUAN 1110 1b:4S A.A.t I 910 bbl 0430 SEC:UR-SA(/WI:MU <br />w2e/2aet 8E:23 2014603433 FIFTH FLOOR <br /> <br />Z00:> <br />PAGE <br />San4Origt.finCelentyEnviroranenIall4Wr . . . . _ _ <br />sw.:4712. IzaPERMII ESE:ft__ 33? g <br />LICENSED CONTRACTORS DECLARATION (LCI:1) <br />I hereby affirm that am licensed under the provisions of Chapter 9 foommencins with Section 7000) of Divisiorl <br />a cfi the Egsinevs arid Professions Code and my license is in full force ard effect. <br />Expfi-aton Date: 16,7 151- da <br />Ctate_ 7 - LO - 0 0 Contractor: c .4 EILS) r SCIPLIPI CLI <br />Title: <br />SI gnaw re: <br />Printed name' P: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby aft rm under pana'ty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a oertitcate of consent to self-insure for workers' compensation. as provided for by <br />— Section 3700 of the Labor Code, for the performance.of the work for wKch this permit is Issued. <br />/nave and wili maintain worker.i. compensation insurance, as required by Section 3700 of the Labor Code, <br />for the ,performance Of tre work for which this permit is issued. My workers' compensation insurance <br />carrier and policy .numbers ars: <br />Carrier: "544 -)r ("amp Policy Number: ) 6,31ac2ii5 —49 2 <br />i ____ certify that in the performance of the work for which this permit is issued. I shai# not employ any persor in <br />any manner so as to become SUbjeCt tO the workerS' cOrr.persetbri laws of C.Aslifornia, and agree that if I <br />stxxiliz3 become subject tn the workers' compensation provisions V Section 3700 e the Labor Code, I shall <br />foithwitt corrupty with those provision.s. <br />sate: _ 7-LO -o <br />Printed Name: -_i9L 0 f _ ,_ 4 I./ 4 <br />w ARNING: FAILURE TO SECURE WORNENS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL. SUBJECT <br />AN <br />EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND tXri...LARS <br />($100,0110.), IN AMMO* TO THE coST OF COISPEMATION, INTEttEST, ATTORNEYS FEEs, AND DAMAGEs AS <br />I fccovmeo•FOR IN SECTION X106 OF THE LABOR CODE. <br />.1.5r-14 (C-57 licensed authorized rapnesentatIve). herrby <br />authorize Set, 6 if <br />1 <br /> to sign this.S.In Jo3qui4t Count, Wen Permit Applleaten on my behliif. I uswiemtartirt this sutherlzatars is valid for <br />i one ti) year arid is limtardta the roost plan elated on the front pa9e at this applicatich. <br />License ;It: (7 53 33 C$ <br />AMC-41.L