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SEP-19-2000 10:09 FROM ORECISION SAMPLING .TO 120946834331 <br /> SEP 1 2000 <br /> EWRONMEN',',L HEALTH <br /> F I P,' 2000 PERMITJSERVICES <br /> 7 <br /> ---------- <br /> . .... ........ <br /> LICENSED CONTRACTORS IDECLARA71 <br /> I hereby affirm that I am lkcased under the provisions of Chapter 9(cornmencing With Section 70W)of Division <br /> 7 <br /> A <br /> ON <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Dew. <br /> V <br /> Signature,. Titte-, <br /> Printed name: 45"VI) <br /> WORKERS'C4 OF-CLARATION <br /> I hereby arkm under penedy of perjury one of the follopMnq dervarations: (CHECK ALL THAT APPLY) <br /> JI(l have and wX maintain a certificate of consent to self-insure far workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> �[have and vAi maintain warkers'compensarion insurance,as required try Section 3700 of the Labor Code, <br /> for Me perfarrinnnoe of tare work for which this permit is issued, My workers'compensatlim bsuranoe <br /> carrier and/pot <br /> pot numbeis are'. <br /> Carrier. o <br /> /14A J j Policy Number: 7 /- G)13 35L oy e) <br /> I oertify that in the parformance of the work far wha this permit is Lssuad, ishall not emptoy any person in <br /> any manner so as to hecorne suNect to the workers'wrnpensatiori lavvr.of California,and agree that if 1 <br /> should become subject to the workers'compensation provisions;of Section 3700 of the Labor Code,I shall <br /> fortfrwit;h7pty With flow provis Ions. <br /> Date: "nature: <br /> Pdoted Nam <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION 00VERAGE)IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND I0-1ARS <br /> J71 00.00.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,AT'TORNEY'S FEES.AND DAMAGES AS <br /> P"VIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> I, <br /> " Lv)—(C,57 11consed authofted represemnv#1 horeby <br /> authorizeQ_ Jk r <br /> _ L<_ <br /> to sign this San Joaquin County Vftl Permit P449itatan on mV behedf. I understand this authoramuon 15 valid W <br /> one(1)year and is tknited io he work plan dated an the front pane*f tuts appliwtio". <br /> INII pa9ea Of <br /> Post-if Fax Note 7671 Date 1 $0._ <br /> TO F-rn <br /> Phone Phone# <br /> Fax <br /> t <br /> TOTAL P.01 <br />