Laserfiche WebLink
OCT-25-2000 09:34 FROM PRECISION SAMPLING TO 12094671118 P.01 <br /> S: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> f hereby affirm that I am licansed under the provWons of Chapter 9(commencing with Section 7000 of Divislcn <br /> 3 of the Guainess aqd Professions Corse)and city kerme is in full force and effect J <br /> rcense# (�;363,7 /J Expitadorr Data _ T/Z—a y <br /> Cabe: �e o Gontracta <br /> 'k Ssgriature: TWO- <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fotlawing deciaradons: (CHECK ALL THAT APPLY) <br /> I have and will maintain a cerAcate of consent to self*sure for workers'compensahm,as provided for by <br /> Section 3700 of the tabor Code, for the performance of the work for which this permit is jasuod. <br /> i have and wilt maintain worke&compensation insurance, as required by Section 3700 of the Labor Codez, <br /> for the performance of the work for whim this permit is issued. My workers'compensation insurance <br /> carrier and p numbers are. i <br /> Carrier: �l T 1A,'141/- P t*Rcy Number: GyC.I 07 Z3-!"T C/Q I <br /> 1 cartify that in the performance of tha work for which this permit is imwea, i shag not employ any perm in <br /> any rnantior so as to became subject to the workers'compensation laws of California,and agree thatfl <br /> 1 <br /> should become subject to the wer"rs'corTensattan Provisions of 5ec@on 3700 of the Labor Code, I shoo � <br /> forthwith comply)With torose provisiorls. <br /> vane: <br /> A-5AbSignatum; <br /> P doted Name: J�4✓� _ <br /> WARWNG_FAILURE TO SECURE WORKERS' COMP914"TION COVERAGE IS UNLAWFt,7G,AND SHALL SU6.rECT <br /> AN EMPLOYER TO C1111111011 NAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (;1o0�DOK1.),IN ADMTION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVED FOR IN 5EC'nQN mG OF THE LABOR CODE. ` <br /> (C-57 ticanae holder),herelyy <br /> author Ze 9 Lam, ��N n vfi tIAC4l ��.g �T�F� �^+u,.. omaulting),to sign this Starr <br /> Jmclt in Cauryty Weil Permit App6ration or my beha*. I undemland 1hia authorize ion is valid for ane 11)year <br /> qnd is)iml*d to the work plan dated on tho kant page of phis app)io*tion- <br /> TOTAL P.01 <br />