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APP -14-2000 12:15 FROM PRECISION SAMPLING <br />TO 12094683433 P.02 <br />oDzz�89 <br />f ooa2�pl <br />LICENSED CONTRACTORS DECLARATION (L!�Q� <br />I hereby affirm M I am Iicen_sed under the preyiuione of Chapter 9 (commencing m(rth Section ?ODD) of Division <br />3 of the SuslhG= and P:ofts;Vrns Codes and my license is in full tome and effect. <br />Lic*n3e 00: j363�59 Expiraaan Qom: I 31 2 od v <br />Date: i� contractor. rQ �• r J D Wt %/ /� y C, . <br />�1 TWe, <br />ICRXF.RS' COMPENSATION DECLARATION <br />I hereby afitt'rt1 Wer persalt}+ of perjury one of tine obllow" dedaraWris. (CWCK ALL THAT APPLY) <br />i have and will rnairrta!n a cer6ftate of consent m self-irsurse for workers' compensation, as providd fcr by <br />Section 3700 of the Labor Code, for the perforrna ace of the work for wfiWi tats permit Is iftued_ <br />x I have and wit maintEfn workers' comwsation Insurance, as required by Seton 3700 of the I a Glade, <br />fur O)e performance of the waA for which this permit -is issued. My workers' compensation insurance <br />cdrrier and pdocy numbers are: <br />carlicr zig � �Lj I I'saticy hlurrraer: 1 z. 1 sss-/-C>v <br />I cerfify %at in " perfbrrnaret Of thQ work for which Ulm petrnit is issued, I shall rAot employ any pepuor In <br />any nwnneer ao as to +b0oorne sub{ed to the workers' ccMpensatian bars of Catifomla, and agree &iat'rf I <br />should becDrne subod to the workers' compensation provisions of Section 3700 of are Labor Code, I shag <br />forthwith comply with those provisions. <br />data•: <br />Printest h act's': <br />WARt+NW(k FAILURE TO SE101.1IRE WORImRs, COWEME ATION COVERAGE IS UNLAVOU , AND WJALL SUBJECT <br />AN EMPLC WM TO CRVANA4 PENALTIES AND CIVIL FINES UP TO ONE HUNDRED Tf,lM)BAND DOLLARS <br />($1 OQ,1i &i IN ADDITION TO THE COST or COtgFOMAflON, ImtEglM ATTOMN6Y'S FWS, AMD oAmA,GFS As <br />PRD'VIDED FOIR IN =TXM 3700 W IVE i.AGM t:tTC4E <br />rO•t c.s7 iic�+nSBld atrtitGltZe'R! +�rnraer+rarvo), hc_cetaT , <br />I-1 sign We San Joaqurfn Coemty W'di Panrit AppUcation on nay behsl[ 1 untfersma�o thlC szprlw�ora fs valid far <br />ee 39Vd <br />Arai is Iimtted to the work pian dated an tho frWy <br />aolrrd HJ.;dId <br />EEV889VG0z 06:VT eeez/zz/ve <br />TOTAL P.02 <br />