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NOV-15-2000 13:03 FROM PRECISION SAMPLING TO 14158991601 P.02 <br /> I _ <br /> U <br /> Z3:L, <br /> o a< I,F d <br /> it; Y. g? i�iII , /+�5 E �, ., . . ..-.�f1MlX "Fri?y�. .F'•..^.. <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I Ixrwby anian that I am licensed under the provisions of Chapter 8 (commencing Witb SectlOn 7000 of Division <br /> 3 of the Business and prokssions Code and my license is in full 1brw and eftct <br /> License J!: 11M 02— <br /> calon Date: <br /> • a Silgttata�: fr <br /> 1 Contractr. cr?4 <br /> �,� <br /> '�?z� <br /> PrJated natter. to Lx.y^B 4. V- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm w4er pe"lty of perjury one of the folkawing declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a of consent to wit-insure for workers'compensation, as provided W by <br /> Secton 3700 of the Labor Code,lbr the perliormance of the work for which this pem*is issued, <br /> have and will maIntain workers'Campensalon Insurance,as required by Section 3700 of the Labor Code, <br /> T for the perfortrrenaa of the work for which this permit is issued My workers'c ompensatioa assurance <br /> c anior and pofy numbers ate: <br /> Canis: M rnrAJ!!f Pollan Number: <br /> 1 certify Umd in the perfarmance of the work Ior which#his permit is issued, I shay not employ any person in <br /> any manner so as to become subject to the workers'Compensation laws of Caftmia, and agree first ff I <br /> should become subject to the workers'compensation prarrAons of Section 3700 of the Labor Code. I shall <br /> forfttHr lb ONT91y with those provisia - <br /> Date: lG S1�natirra: <br /> Printed Name: M uW4K� SSE <br /> WAR W;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EIMpI.CYER To CRINNAL.PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANla DM I.ARS <br /> d;IOO,OW.X 11dApf3.MONTO THE COST OF CQ ATION,INTEREtrT,ATTORNEY`S FEES,AND DAMAGbS As <br /> pROVEM FOR IN SECTLON 3M OF THE LABOR CODE <br /> I1C-S7 Rev toad mAftofted reprmenrati ),hereby <br /> to sign this Sen Ion Coen far V Ill Permit Apprfca6m on my behat#. I understand this authorizab m Lir vaw to? <br /> one 1 and Is Hmifsd to the work plan dated on the front page of this application. <br /> ,., ,....� .,...•„ ,.. ,. ..,._.,,.,._,... _.., . ._ ,....TOTAL P.02 <br />