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DEC-14-2001 11:5@ FROM PRECISION SAMPLING TO 1915E610430 P.03 <br /> FIDE COPY <br /> n j Cap* $i fieam sem UM IV W10 petmft ftgAwwm supoemem <br /> .SOB AWRESS; PER�At'E` SRS: <br /> I- CP, <br /> UCENSgD CONTRACTORS DECLARATION QQ0 <br /> I hsraby altirm that 1 am fxer"d under to pmtsi5ior►s of Chapter 9(orsntMCr4 9 w01h3e4SM?WM of Diw+stoft <br /> 3 of"ausro?ss and pngessia:s CcW and my 9mr+8$N In tug tone and effect. <br /> t.kvftse aw G 3 G 3 $ _Fgratian Date: <br /> Slgrtawrs; <br /> ¢.,/ <br /> Prhytn,d namte: <br /> WORKERS`COMPEMSATtOK DECLARATION <br /> hereby affirm under penalty of perjury one 01 the fvtiowiN ded--ffR ions: (CHEM ALL THAT APPLY) <br /> .�i bave and wit malnWn a ce:tfcats of aansent to sal 4mure for workers'compensation,as provided for by <br /> 3m of the LaW .for fhe pertwmarx:e of the wmrk for whk;h this Wmft is issued. <br /> i ham a- !!anairrtain WWkWW oornpensallon in9mo 1° ,as required by Seaton 3700 of&a tabor Code. <br /> ,or"Psrformanoe of The work for vA*h this pemnit is Esus& My worikers'GORWn"tiori irtsurar cue <br /> catrAar and numbers aver. <br /> Cerr'ier: <br /> � e.,4 ,1�"�� Ftancy Numbst. # ? t.3 3 9— 10 <br /> I certify that in the putt ante of the v"k for v&fth this pamR is issued.I WOAt riot emPW anY person in <br /> arty manner 30 as iocomt>Aaw sutiect Io Z w0rU s'=r s UPn taw®of Califon,and agree that if <br /> t <br /> shmW bee subject to t w WO&Ors`oarnPgftgatt M provisions of Section 3M of t e tabor Code.t 8W <br /> foMwith comply with thous prOM . <br /> Date: Ste' <br /> Pr1171t3d Nerve; <br /> wAfwtf =1FALURE TO sacuRew F_SS AN,) Up To oN �TIJO i�UkRS gCr <br /> �,t�!ERMAVER TQ CtlaltML P 0L <br /> (1100,0N.16 IN ADOMM TDTHe COST OF CAtl PUMAticltf,tMREST=Ano FEM AND DAMAGES AS <br /> PRO FQR IN Rg 3705 OI=7?�i;LABOR 000E- <br /> r JJr� Isignatar+e VIC 7 FavemW sue oepreseetsl"L <br /> to Agg fhi;s Scut.Idaqun Ceuut7f <br /> Wen Permit Applasson an mY betta& I nn*w1*nd tm ejMmtte*=is va2d for <br /> am �and is nwjl ed to 1w wc&PIS+dated oa the tMat pegs pt tits OW'ca ons <br /> 547400 f US <br />