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OCT-04-1999 16:59 FROM PRECISION SAMPLING TO 12094683433 F-0d <br /> r• <br /> Sae J*"Oifl Cauf1ty Einnrartrrtwnt Swiv Rm,tJr*IV tf%9 Peenill App On UpOWTH t <br /> JOBADDRESS: ,( PERM1T <br /> C SRS• <br /> LICENSED CONTRACTORS DECLARATION WO) <br /> I hereby affirm that I am licensed under the ptioVWM of tempter 9(comme►nang witn SscWn 7WO)of 07msion <br /> 3 of t"Business an�ld.,Pn***rw Codd and mit Be, is In tut torte and el►�t <br /> l iae»se# „$ -- - g piration Date: <br /> lam: <br /> Signadturs: ,� Ti'tEe: � � r`i�=1^- <br /> Prblhd� <br /> WORKERiif'COMPEpSAMN i ECLARATIOM <br /> I hereby a&m undor porrarly of Wriq one of 6W k4awmS decbra bores: (Cke"ALL THAT APPLY) <br /> 1 have arta w1A nwkfti:a ceMrate of acnwnt ba teff-insure far worse W cm,pwrrsafiun,at;pmvlded dor by <br /> Section 3700 of the Labor Code,for the perkxmmoe est Ifte worh for wfth this PtmA%=uad. <br /> t have and wilt Main vvoeWW aonpmeation msura we.as mqulmd by Section 3200 Of the Lubar Code, <br /> for the perfi"wce of the work lbu which thio pw rnit is used. My%*4W 'oornperxati0n iniutanOe <br /> carrier arae polar numbevs enc: <br /> camera Policy piumber: - <br /> ,,,,�1 ftt in tfte perbnnt m of flee Work for which this pwmk is issued; t shalt not ampk3y any pemm In <br /> arty marurer so sit to become sui*d to rhe tworkers`compensation tsars cf(.'aiEtiamia,and agree that if 1 <br /> shouid become subject to the wadoeW ompotabion provisions of$teflon 37000f the Gabor Cpde, I WWI <br /> WANAh campy with thane pwsians. <br /> Dals: Siprrabos: <br /> Primed Name: <br /> WARD NG.Flllt.R PA 70 SWURE WC)Rli1tiRV*OWSwArOX GGYEiiJ16E 6 UNLAWFUL,Mil!SK4M at03tcC f <br /> AN V1AYER TO CRHMAAL.PENAL nES Amo crAL mm up To oNE 1 umomDTmousAND not_LAA <br /> M406NO).01 AtloiT{oiil TO THE CMT QF cOlYtPUMATICN,irrrERWT,ATTOOMrS FEW ANn cu►iR+665 A3 <br /> PRUMNP FOR IN SEVMN Wes OF TME LA90R Ccfoa. <br /> 1• � c-b7 lioerl3td autlteeioaed rept+ese�ltlneA ilete.4y <br /> auntortse tp <br /> to sign ihn Sart.Joaquia County WeR Pse mi piigtietrr on my behalf. t umi dorm and tlties ae+tlene�stivn is slid for <br /> vete t1 acrd is fienlistd tq See wo�1e tladd an tts.6owt of'this ver. <br /> P Dore v1 a a- <br /> Post-a' me i� 1� <br /> v L <br /> TOTAL P.02 <br /> TOTAL P.02 <br />