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NOV-09-2000 11:1e FROM PRECISION SAMPLING TO • 12094GB3433 P.02 <br /> .San Anterty Fnvhnw meftf fleplth:Sen&ads Unit IW WeII Pemna And67Wart supple***: ... <br /> f.J�I'13A�]D#�ESh5• . P�EIT <br /> LICENSED CONTRACTORS QECLARAnI ON (LCI�j <br /> hereby affirm That I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions code and my license Is In full force and effect. <br /> incense# Expiration Dale: E <br /> Date: rLa x. <br /> Signature: T'.tte; <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION { <br /> I hereby affirm under penalty of perjury one of the toFlowing declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a ceatifibave of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the pertormance of the work for winch this permit is issus6. I <br /> I peva itnu will mbiiIlaihI as rwi;v.'by Sidon 3702 of the tabor Colo, 1 <br /> t^vr the per k ivmaic�of the Pi,7k;•v::i.''„'.~,T„pw':n iL ww,.::. f ty t'•'.^.rkv.s'CL•r^.pPllSatlIXh insuraRCe <br /> and.-icy, n„mhem aro: <br /> Carrier. Polley Number: _..—I cer*Oat in the performance of the work for which this permft is Issued,I shall not employ any person in <br /> any manner so as to become subject to the wvirkers'compensation laws of California,and agree that if I <br /> should become su*wt to the workers'compensaUon provis'rons of Section 3700 of the Labor Code, I shall <br /> forthwith compry,with those provisions. <br /> trate: Signatilim: ,I <br /> ,�Irftw �wr <br /> WARNING! FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES IIP TO ONE HUNDRED THOUSAND DOLLARS <br /> 1 ($100,000.),IN AODMON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FMrS,AND DAMAGES AS <br /> PROVIDED r'OR IN SEC70N 3377006 OF THE LAB['1/�,R COOL <br /> I, IV `/-'Gr'1 (signatureof -577llic-ensed authorized/representative), <br /> hereby authonxe(print neuro) <br /> T I loll ,rCr 1 1 r Cy/ rcY <br /> ^ � <br /> to'sign this Sari Joaquin County WWI Perrmlt.AAplkattlan on my bet;alf. l undors`..rid ift;;authad7ation 9s-+aIid for <br /> one(1)year and is Invited to the work plan dated on the front pane of this applic4lon_ <br /> I"7-20M I MI <br /> TOTAL P.02 <br />