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SEP-19-2000 10:09 FROG 'RECISION SAMPLING - TO 120946834331�lpl a\y <br /> fa, <br /> SEP 1 2000 <br /> FNV!R10NMEN-V\L HEALTI <br /> 6- P i pFRMIT/SERVICES <br /> Hv <br /> e IT <br /> v <br /> LICENSED CONTRACTORS DECLARATIO LLCD) <br /> I hereby affirm drid I am licensed under 0-te provisions of Chapter 9(commanding with Section 700)of Division <br /> 3 of the Business and professions Code and my license is in full foroa and effect. <br /> 6SG3t-1 Expiration DaW�- )/:I/ -?-.0-07.1 <br /> License#: . .......... <br /> Dew. ?//47 A-10 Conh-acwr,. a e- <br /> lf I <br /> Signature, Title; 9 <br /> Printed name: /5". <br /> WORKERS' COMPENSA71ON OF-CLARATION <br /> I hereby atram under penalty of perjury one of the follovAng dec4aradons.- (CHECK ALL THAT APPLY) <br /> �l have ON WSI maintain a certificate of consent bD self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the Work for which this penrnit is issued. <br /> �j have and WiM rnaintain workere compenseffion insuraTice,as mquired by Seofim 8700 of Iiia"boor Code, <br /> for nee perAwmnnoe of the work for whlc�i this permit 4q issued, My workers'compensation bsu rance <br /> Carrier W1201 numbers are: <br /> Carrier- policy Numtaen 6-)"-i-67 1- IG-)1,3 S�-- OJ 2) <br /> I oertify#0 in the perforri-ranne of the wcwk for which this pwmit is issued, i shall not emptoy any parsM in <br /> any manner so as to become subject to the workers'compensation lawn;of Caffornia,and agree that if I <br /> should become subject to the wo*ers'compensatiori provisium of Section 3700 of the Labor Code,I shall <br /> fortfivvith ply withftse provisions. <br /> Date: 7 () <br /> plioted Name. <br /> WARN INS:FAILURE TO SECURE WORKERS'COMPENSATION COVE OVER OF IS I,JN I AMM I L,AND SHALL Suej EECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINER UP rO ONE HUNDRED THOUSAND I)OLLARS <br /> ($100,000.),IN ADL*TION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> pRMOED FOR IN SECTiON 3706 OF THE LA13OR CODE- <br /> 1, 1,&A^ Urltlwnl tC-57 11censedmithoAmd rvpmzevWnv#J%horeby <br /> jkq- <br /> % '9- u� <br /> aufhar4n GL I"V\ e(' <br /> to,sigo tins Son.Joaquin County Well Pernift P4WitaftIn on my behalf. I undambsnd this et thortnaUon ts valid tor <br /> one(1)ywr and Is limited to the work plan dated an the front page of tlift appliwtipo, <br /> Post-jir Fax Note 7671 Date ► <br /> Pago$ <br /> From r <br /> To <br /> Phone;f Phone# <br /> Fax—il-Z Fly 4 <br /> TOTAL P.01 <br />