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1 --juu1 13 08 FROM PRECISION SAMPLINu iuaz <br /> r:• _ .. — r..L' .�'!wt 'r'E,^ ••�. .r•6•. <a 15 , '!Lk.y. <br /> ff.-ItLie <br /> .r,••a._ p rt*- �'�'i ,'A'A.':�. _'„i.^ �.�;.sz.:ey M;s1�:"eq!i!,':"jy - ':�t;�`i__..3-.:r-.. T-J�...�.` — •`• .,.:Q.�� 1_'�iipit ri a�1 P 0, . •.l= <br /> LICENSED CONTRACTORS DECLARATION <br /> 1 Hereby affirm that I am llc8n and under the provisions of Ghaptsr 9(V=rnenc v vft section 7000)of D'+rision <br /> 3 of the eusir and pmbeafons Coco and nny license is in full forme and eta <br /> License A �Q„ IE:xPia6an seta: t f 02- <br /> t>a� —� <br /> glgr�ur*: <br /> TwK <br /> PrTntad nam: M< <br /> WORKERS' COMPENSAMON DEGLAR"ON <br /> I hereby aMM7 under penalty of perjury ane of ttie fdkM tng de ones: (CHECK AU.THAT APPLY) <br /> 1 have and will maintain a ceItticate of consent tom of the lbr pnsab n ��reeridad for b <br /> Seefion 37DO of fie Labor Code,for theperforrne <br /> I neve and will maintain workers'oom on Inst mm=, as required by Section 37M of the Labor Cade <br /> tori fhe perfom>an®of time vMo�c kx+which this perrr>�is ias+aed Ealy wdicers"spa Qtsurenaa <br /> aamtw w w poky numbers are: <br /> carrier. Irl UTI�/l-rte Poor Numbs- <br /> „L I mottyr mat In aw p,erNmancs of the work for whith tlhie pemlit is Issued. 1 stwd not ernpioy any Person In <br /> any manner so as to becaMG subject to ttto wwlxtww compensation lews of Cal fornia,and agree that If I <br /> should bacgmB subject b the vrcrkene compermti,in tircWsk g of SeecWn 3700 dF Ito Labor Code,1 shall <br /> fordlvirifh Com#v Nrith those provision& <br /> Date: 4/1,2/Q l z%pah". <br /> Priwdod IWrne- <br /> WAFt1' M:PAIL IM TO 9ecuRE WORKERw Co�1SAT10N COVERAtitc t8 IJNLAINFUL AND BFMLL 9tJB.lEC T <br /> AN E8111 LCYER TO CRIM14AL PENALTiEB AND CML FIRES UP TO OKE HUNDRED T US"D DOLLARS <br /> J6100,00. FOR IN R <br /> Ili <br /> ITVOW TO <br /> THE COST OF 7'70617F THELABOUR COAUM,VI TERE ,A'fTOWfff'S FR@Sr AND DAMAGES AS <br /> PR <br /> -67 AoensAd and wrtsd tiimmme.ftdrw),OWN oft <br /> ailalat�s <br /> to sign INS am jgo*An zaunty WWI pow..it AppIlWa n an my betfa 1 undra amm oft au tntfation in vaw for <br /> one 1 and b UMMd to the wo* dated 00 the*Or* of this IeeWn, <br /> 7(a ��'.-! L!"l(11J Li I -�T-1 �CI'COC�r!'77 Cn'TT nr,f"i7 ITT JI`rl <br /> TOTAL P.O2 <br />