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AUG-11-1999 10:35 FROM PRECISION SAMPLING TO 12094083433 P.02 <br /> I <br /> JOB ADDRESS: t'`J _ PER1AU: <br /> LICENSED CONTRACTORS DECLARATION <br /> I l-mby affirm that! am rioensad under the provisions of Chapter 9(oorrvWncing with Section 70010 of Division <br /> "s of the 8 Siness and Pretensions Code, ar,Q my license is in furl force and effect. <br /> 11 <br /> License S� (i34,'o Expiration Date <br /> •s <br /> 1 Date Contractor P,,04-.VO4 :5-0t�al,4, <br /> Signature � <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm undef penalty Of perjury one of the following declzrations. <br /> I have and will malntain a certificate of Consent to self-insure for workers'compensation, as provided for try ! <br /> Section 3740 Of the Labor Code, for the PerfomWCO of the work for which this permit is issued. <br /> I have and will mairmin workers'compensation insurance. ab mquwed by Section 3700 of the Labor Code, <br /> for the pertwmancae of the work for whicl-this permit is issued My workers'compensation insuranre carrier <br /> and policy number are: <br /> Garrier �� J► Policy Number <br /> I I certify hat in the perfomtiance of the work for which this permit is issued, I sbali not employ any person~ ;n <br /> any manner so as to become subject to the workers'cOrnpermation laws of California, and agree that if I <br /> should become subject to the workers'rompWsaticn provisions of Section 3700 of the Labor Code, I shall <br /> forthwith corrrpfy with those provisions. <br /> Date Signature: <br /> WARNING:FAILORE TO SIBQAU WORKERS'COMPENSATION COvERAGE 13 UNLAWFUL,ANIS SWELL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PO4"TIES AND CIVIL.FINES Up To ONE HUNDRED THOUSAND DOLLARS <br /> (100„000),IN ADOMON TO THE COST OF GOMPEN3ATIOK DAMAGES AS PROVIDED FOR IN SECTION 37V6 OF <br /> THE LAIKM CODE,INTEREST.AND ATTORNEY'S FEES. <br /> TOTAL P.02 <br />