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OCT-27-1999 10:28 FROM PRECISION SAMPLING TO 12094683433 P.02 <br /> r <br /> San Joaquin County EwAroi nit"tat Health•Senlioes,Unk IV wii Iderinit Aphpkation Supplement <br /> [JOB ADDRESS:-1, ' ' <br /> \MV-5,0P PERMIT SR*: 62-1 Od O <br /> LICENSED CONTRACTORS DECLARATION (LCW <br /> I heresy affirm that I am licensed under the provisions of Chapter 9(cor„mencirg with Section 7000)of Division <br /> 3 of the Sustness and Protessiors Code and my license is in full force and effect <br /> License#: Expiration Date: <br /> DateAQ • 7(0 44- 1 Contractor: 5t0o 4Sly+ laC� . 1 <br /> Signatum: Title: M�� <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION I <br /> I here affirm under penalty of <br /> by p ty perjury one of the fotkywing declarations: (CHECK ALL THAT APPLY) <br /> I have and witl maintain a cerWicate of consent to sell-insure Iot workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the perforrrnance of the work for which this pe+mit is Issued. <br /> have and will maintmn workers'compensation insuranoe, as required by Section 3700 of the Labor Code, 1 <br /> V the perforrrarce of the work for which this permit is issued My workers'compensation insurance <br /> canner and, ��poici�.y numbers are: <br /> tamer. -;711n r. <br /> LAG Policy Number. �Zl <br /> I certify that in the performance of the work for which this permit is :sued, I shall nct employ arty person in <br /> any manner so ac to became subject to the workers'umpensaW lays of Cafirfornia, and agree that if I <br /> should become subject to the workem'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with inose provexxiis. <br /> XDom; l Z(� _signature: <br /> i PNrTted Name: _- 1A `' �} 'C�C —• <br /> WARMING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EIWLOYEFt TO CRrWKAL PENALTIES AND CML MRS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,W.),IN AMMON TO THE COST OF COMPENSATIOlh, INTEREST,ATMRNE7'S FEES,ARID DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> (C-57 licensed authorized roprreserttattve).hereby <br /> autl�ize_1���� �G C7D�1.1� d�% 1G%tbc�"� �•l�/t Y�1.1 IV`Y�-�cL� <br /> to sign fts San Joaquin Coun%f WoU Permit Application or my behalf. I wedw tend this authorization is valid for <br /> E <br /> one(1)year and ie IlrriRed to the wwfc pian canted oro the frart Qa>�e o1 tlhis aPpNpgon - -F� <br /> T d -- <br /> TOTAL P.02 <br />