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MAY-11-2000 12:00 FROM PRECISION SAMPLING TO 12094683433 P.02 <br /> .Met-p- s Uj. << 0 z <br /> 7 <br /> M. 'R1it,�[r�T�.S�SY �� .Mw r' A �f.k3 '.'� ;c;-'� _1�=��'• C �' g �7G�Svyir�.:l�i.. <br /> _ i - — 1.1z a ^t.. <br /> -N, <br /> ��• ,7L y .� X;a�� <br /> i !1'F 17.1 �3f luC��•11/A Z�•r • +� 4� i'Jil.',�i .IL .n��6Y_ri��-+;II� _ <br /> � s <br /> r <br /> � cc <br /> _ _ _ .. �,. -. ... :oi.:...�'• r. < t A M1:C3ys 2Mi <br /> LICENSED CONTRACTORS DECLARATIONLL CDS <br /> I hereby affirm that 1 am 11cessed under the pro0sicns of Chapter 9(commencing with SecWn 7=)of Division <br /> 3 of the Business and Prokssions Code and my license is kr tt,dl force and efkx�t <br /> LicenseA, �D%�P `t1 i Expirat n Date: <br /> Dates t Contractor: Fr? 1 GI1 ON � l�lil 0 <br /> • -'� Signature: � Tom <br /> Printed nattre: <br /> WORKERS'COPAPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followirig declarations: (CHECKAI L THAT APPLY) <br /> 1 have and will maintain a Certificate of consent to self-insure for workers'compensation,as prom for by <br /> .,.—Section 3700 of the Labor Code,for the performance of ttte work forrMkh this pear-A Is issued. <br /> I have and will malrNain work&W oompensation Insurance, as requil-d by motion 3700 of the Labor Code, <br /> for the perbrrrrar,ce of the work for nfiich this permit is issued. My workers'compensation ets.tmnae <br /> carrier anti policy numbers`are: n <br /> Cartier. / 1'V IJ _ Policy Number: <br /> I certify that in the performance of the work for which this permit is Issued, I shag not employ any person In <br /> r.,.. <br /> any manner so ars to become subjed to the workeW compensation laws of CaRfomia,and agree that K i <br /> should beoorr+e subjed to the workers'compensation pna(sions of Section 37QD of the Labor Code,1 she# <br /> fort with cfnornpfy with those provisions. <br /> • Dale: "/� << Stgnalure: <br /> r 1 <br /> Prirftd Narne: rA� 4A:M <br /> WARMNG:FMLURE TO SECURE WORKERS'COMPENSAMN COVERAGE IS UNLAWFUL,ANP$HAL.L SUBJECT <br /> AN EMPLOYER TO CRIM MAL PEN AMES AND CMI.FIN'S UP TO ONE WJNDRED THOUSAND DOLLARS <br /> (S1006=.j,IN ADp1TiON'10 THE CM OF COMPENSATION,INTEREST.ATTORNEYS FEES,AND DAMA61S AS <br /> PRD' MI)FOR IN SECTION J7�0tis�OF THE LABOR CODE <br /> 1, Ff61 C,l i(/ Ci1 t /'ill <br /> __IC-57loerseed aut wriasd rupn"tt diwt,herby <br /> auarartie TODD L�Ar�. o� ( ,n H 8�t X <br /> to sign Bds San J*vq&An County%%II Permit Appric aftmr on my behalf. f urrftrstaM W*muftwbaSon Is valid for <br /> one t r and la Rmited to the work an dated on the front of this ypliontion. <br /> 713 7C1f!J VPfT1.I I.f 1 IT T' Iw/.rl.^-��r.sY �.+• try <br />