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APR-14-2000 12:15 FROM- PRECISION SAMPLING TO 12094683433 P.02 <br /> r ��� /755 Z41 //)F:6- <br /> r Mi <br /> ds�C� e1� s q <br /> _ � �� e• vy<n�� ',�°�_�. ��c�:"C 9� 1j` <br /> rr >'-ry",.'_ .c� - ,`�ilrf� 1CE �'t:il nL'-s�1iF�!�vn h1G��"1';'•I-. <br /> 7. •.M. iil 1-'. .� �rix�.�=ii_'" iLI�G� I fi.�'T..�•IP� s'�5^ C`'.'f.t <br /> V �'jw�`vi . -4,5' -. <br /> F.:� MIt�'�..:'R•ri'1..4Q' .. ,.. -. '�:rw:.'.:..;:,:ir .3^.:.;;�C:.:?'`. {i�l�I�MC.::':• .rn.n (�f. <br /> LICENSED CONTR AC RS DECLARK fON (LCD <br /> I hbereby affirm M r am rzens under the provioioM of Chapter 8(cormnencing with Serthn WW)of Dmsiun <br /> 3 at the Buslrm=and Profawiasns Cr>de Aq) {my license is in fug force and efkct <br /> Expimun�: 1 3 <br /> Dake: i� cbntractar. Tea S G <br /> W0PjMR8'C0MPt rzAT10R1 DECLARA-111110N <br /> 1 h&'Mhy SfFM unser Per'04 Of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have arrd wA maintaln a certftate of consent�Self-insure 1011 Workera'mmperisation,as prowidad for by <br /> Section 3700 of the Labor Code, far the pwf wmarze of the+cork Tor whim ros permit is jaawcL <br /> xI krsve artd wit mrabItafn v mrkers'Cvmpensatlw kmurarme, as required by Section 3700 of 1he Labor Corte, <br /> for the peftwMice of the warts for which this permit is issued. My workers'0 rnpensawn Insurance <br /> carrierand icy numbers,are: <br /> Cam.,. c�e i � � Policy Number: 1 o v <br /> �!oellify that irl the pe rife of tha work C9r which#t%perrnit is issued, 1 shall not employ any person rti <br /> Bny MRnnW so as to 1300MM Subject to the Wortcets'aarripertisatian iawus of Ca oml;a, and agree OW K 1 <br /> should beoane subjecito the workers'compensation Pmvir-kms Of Soden 37th of fit®Labor trade,I shag <br /> forffm'th cm Mly wilt tme nisi & <br /> Date: <br /> Printed MMe: <br /> WARAM M FAILURE TO 3£C'k7ia;WCIIaDMM'COWE'MSATION COVERAGE IS UNLAl1lr UL.AND SHhLL SUBJECT <br /> Ari EIWLQYM TO CIMIMAL MkALTIES AMD CML FINES UP TO ONE HUNMEC FHOl1&%No DCft.LAa$ <br /> (11400,01Wt IN A 0M1T*M TO THE CMIF Or COMP AT9K INTMaSY,AT773r1NF"FE$$,AILD DAE1tAG6S A9 <br /> PROVID FOR IN STM 37W or THF LAGM CCep-- <br /> r Bd mime,l dt r t �rtatS�ro),hereby <br /> to mig"WO gat,JWiILdn C012AY WZU Perm itAppi Icatfon on my b0hblL I vnftrss9t a lhia aLdtwixataxr Is valid for <br /> arw 1)Yew and is Iinsha l to ltl-week PAM dated an&A from MM of this apelkafion. <br /> 08 39ad aoon� HL-�2� EE0869b68Z 08:0T 0082/LTA <br /> TOTAL P.02 <br />