Laserfiche WebLink
APR-27-2001 14:46 FROM PRECISION SAMPLING TO 19494740c940 P.03 <br /> R <br /> :: e• +"x.! f ` `'� . �7'' <br /> UCENSED CONTRACTORS DECLARATION (tel <br /> I!"by oftm IW i am llowwad underthe provWons of CtepWr 9(comm zing vrftfi Seftn 71300)of Ctivieion <br /> 3 Of ft &nuress and PI 11C Coda and my license is ht M kne and e>� <br /> Lirartri9eO0/hfD� Ekpka6m Date; --- <br /> DaW `i L 7 v roe,�eelor: •I�Ohl <br /> 8lprreWrtec '9 Tft1 bazg-,- <br /> pdW%di name: <br /> WORKERS'COMPEMATION MCLARATION <br /> I hereby aMrm under pawl y of perjury aria or the Topa deckwuUm (GW-GK ALL THAT APPLY) <br /> t nava end will rMinigir:a ceditats of==ser m <br /> self-Insure fef�rorkara'sampenRallob,as provided for by <br /> Secdort 3700 of ft tabor Coo,for the pwiom sr=of the to*for wftitfr aria Wffdt ar bnod. <br /> I hava and will rnslntMn*miters'oomperwt on ir"lrxe w, es required by Seclton 3700 of they Labor Goode, <br /> 4 lbr the perkxt mn4e of ft work for which tft perm It is Wmjed. My workw*'Cornpertsga ineurti'noe <br /> carrier end poicy nunnt m am., <br /> COWer: {Ae l� Poky Nuntibsr: �O�-!�q l-7 2�- <br /> I rerfHy that In tee parformanoe of the wft for whim►this permlt is*sued, I shW not wnpby any person A <br /> anfr mamar so as iu become aubjed to the workers'compenss0on laws of C*flfbrnkp and agree thsl V t <br /> should beoama subject to ths,rrwkers'owpermWon pWaiana of SSCtEaa 370D of the tabor Code, I <br /> torttma ax"wdh ftm pmworw <br /> Printed dame: t'A " <br /> VOJVAga:FALAWTOSECURE VMFdCW$'CC>MM8ATiON CONE RAGE IS LWLAWFU,.,AND SMALL,t usjEcT <br /> AN lMIPt.NM TO CF4WAAL PEM1ALTM AND OW FN UP TO OKE N WORED Tf OUSAW DOU AM <br /> d;t Oo,tiWD llt ADDRIGM TO TNI OOWr OF COif94INSAT1Oti.1NTEFUW,ATfORlIE"Yui$,AND DAMAt AS <br /> f PROVOW FOR lit SECTION 37M OF THE iia CODE. <br /> 4 Boomed mAkwhod+raprwrenlrAtr+rl,hiersbll <br /> { .utiroraa. � 1� � VVf <br /> tie alga this f3a,fosgrdn Courdy WWI Penna AMAcittlon an my bdmfC. I undersand two aulhortzaakan it vale ft? <br /> *M(1)yeW a'b wailed to f w woek plan de ad on the Nara~of this llosltan. <br /> TOTAL P.O:f <br />