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MAY-11-2000 12:00 FROM-PRECISION SAMPLING TO 12094683433 P.02 <br /> ., _�At 'c 7. cb iry•e F;i T�;p_-- '��.r:. :P.!.��.}�-d a �riin� - <br /> 7'y-1::�__�. <br /> ��,�i`� � i�tc..•F:�>. .1' - :•;,�.,. .5t5.rrz::Ti=r':.:, ,_ -_,x_:�y7r.k�• _:y Nrs`�r�."r'�.. ,+.q.. = . <br /> _ - - _ -____- - e'br'rci7:•+"'' ° __ _ ;y:lw - _ -v.,,`•l.'�rb�_�ifa[r„;•y. CY•_ <br /> "'!` <br /> a� _.ai`�."EG ''"i'6�i": ':^- - - '�'F:,`: .nom. :�'_'n. -aa•.$:::.._l:_��: ';,. <br /> ','..3n�,_::: ,.�_v�' - __ `^`' •�-' ':>Ct-.l 's���_ .•iS!t. rx�nv iSr �.'�� <br /> ::r• <br /> .... �.• iyr_.:i '��•.,.. �. w ..,u�1ri,;:L n'� �c;'i-:- - _ - `- 'e=i--s --- '•%'..'-----�r � -- � .~?�s.r <br /> :. p".-n,4i"iai:c xo...:.::.:r..• .'._..^ r�-.,'.+ ....::w.,. i''L".✓ r Hiifi"a_i' !�:•a4,� <br /> 'iHi�",2vr.:.-.3.:. .•J�,•.2C. -t.W.�_moi.'.. �.,. -. .....-:_ ._ ... - _ ._ - ''�tti_:r'�-.. . .....,�iat.� _.ti.:yl.,{,tal 57tt.RF!lf�d�;�:`•!a <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under me prow fans of Chapter 9(commencing with Sed)on 7000)of DMOlon <br /> 3 of the Business and Pro ns Code and my license Is kr fi dl kwce and effect <br /> t_itaer�se�: f D�71P�7� �ilaticrrr gate:_l?�i 1►'�iyZ7'1� <br /> contractor: '. it�10l� t I�t N�' ! C. <br /> - ftnntuf : Tltlae3 ers LL.Rya <br /> Pdutad narlfe: <br /> WORKERS'COMPENSATION DECI„AR/TION+1 <br /> I hereby amrm ander penalty of polury one of 0'a following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a C,effeate of consent to self inauta for mf:xkaW compensat m,as prc lded for by <br /> Sectlon 3700 of the labor Code,for the perlommnoe of the work for which ff*pem*Is lanced. <br /> 1 have and will maintain warkers'Compensation Instance, as requfted by S .3700 of the LaW(`,ode; <br /> for the wee of the work for which this penult is issued. My workers'conVensa"M insuramr e <br /> carrier and policy numbers are: n <br /> Cartier. / CIAD . Po&7 Number, <br /> I CerVV that in the perbwance of the work for which this permit is issued,t shall not employ any peraon In <br /> any manner so as to become subject to the workers'compensation larva of Ca3Ybmia,and agree tfrat If I <br /> should bec" na subjed to the workers'compensation pm4afone of Section 37GD of to Labor Cade,l <br /> forthwtth darn*with those provisiWs. <br /> Lute: X11 ll { �b sierraa,fs: <br /> Printed Name: tv►l <br /> WARNWOi:FAILURE TO SECURE WORMW COMPENSATION COWRARa is UMAlll FL)L,AND SMALL SUILIECT <br /> Illi EmpLc YER To CRouNAL PENALTIES AND CIVIL FIIES UP TO OME WJNORED•THMSAND DOLLARS <br /> ts1 ftow.) IN AbIWIO N 70 THE COSY OF COItlPENSAmN,FNTEREST,AT TORNErS FEES.AND•DANAGI S AS <br /> PROV01W FOR IN SECTION 37�0y6 OFF THE LABOR COM <br /> 4 R1 � (fit%1/Y r.W Moerraed aedwdmd hereby <br /> autharhoe � D� .o l X _ _ <br /> to sign 0"Son.Iosgrrin County Well Pw.A AppNcaflon an my bdmff. I untbn wW this aulhektr 0m Is vaNd los <br /> one VW and In Hm ted to 2wvmrk an dated on fhs(tont pof this litstbn. <br /> 70 <br /> ^TOTAL P.02 <br />