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SEP-19-2000 10:09 FROMPRECISION SAMPLING TO 12094683433 <br /> NNW/ <br /> 2 SEP 1 ' 2000 <br /> NMENTAL <br /> SEP 1 8 2000 ENVRPEROMiT/SERVICES HEALTH <br /> RAU <br /> V[CE.7-".- �FU`'5345 :9------ <br /> V <br /> in <br /> �a <br /> "2� <br /> 2 <br /> L "p <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> J <br /> J hereby affirm that I am licensed under the prGvWorm of Chapter 9{commencing with Section 70W)of Division <br /> 3 of the Business and Professbris Code and my license is in full force and effect. <br /> 3 Expiration Date:License#: 63GI/:I <br /> Dew. 9//V/m, ­0 :r—,he, <br /> Tift, C? CC) <br /> Printed nanv: <br /> WORKERS'COMPENSATION OF-CLARATION <br /> I hereby arum under penalty of perjury one of the follovAng declarations: (CHECK ALL THAT APPLY) <br /> l haute and will maintain a cartlflcate of consent to self insure fbr workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the peftrmance of the work for which this peffnit is issued. <br /> a <br /> )(I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance at the work for which this permit is issued. My workers'compensation hwrance <br /> carrier T numbers are: <br /> it 0. - <br /> Carrier. Policy Number: 3.5— <br /> I certify that in the performance of the work for which this permit is issued! I shall not employ any person In <br /> any manner so as to became subject to the workers'compensation laws of California and agree that N I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> lbriliwith ply with ftse provisions. <br /> Date: 7/17 A)ej signature: <br /> printed Name.• �,-_1 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNIAWRJL,AND SHALL SUFUECT <br /> AAT EMPLAYER TIO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1 00,060.b IN ADIXTION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY-S FEES,AND DAMAGES AS <br /> PRoVIDED FOR IN SECTION 3706 OF THE LABOR CODE- <br /> 1, YA (C-57 ftonsed;authofted Yvpmwr=tIv#),Iweby <br /> au#harL"_-1-- <br /> ta,sigo thls Son Joaquin County VftSI Permit P4*11taftn on my behalf. I undanftnd this authWhzUon is valid W <br /> one(1)year and Is limited 1b the work plan dated an the front PqJj&_pttI*S application. <br /> 5-17-x000 l 11A1 <br /> post-ire Fax Note 7671 Date <br /> T. 7�Ire F-rn <br /> co.yDept, <br /> Phone# Phone# <br /> Z;@ 39Vd <br /> TOTAL P.01 <br />