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DEC-14-2001 1149 FROM PRECISION SRMPLING TO • 19166610430 P.02 <br /> Pan Joaquin County EnvlronmeMat tieaith Serv➢ces ilnftLV weN PermLt Alaptltxstfgt!�ye4igmant <br /> JOB ADDRESS %y��t�—� PE�'�"9T SR*'. <br /> LICENSED CONTRACTORS DECLARAT'ON UP) <br /> l hereby affirm that i am ioensoG inh,r�r�rsiorts of Chapter 9(commertcing with S00tiOn 7000)of Dwisian <br /> 3 of the&rsiness and Professions Code and my license is in full force and eftecf. I <br /> 6363$Z <br /> License Expiration gats:- t �3 <br /> EYdt3: (:olwtraClOr: <br /> Slgnaturri_ <br /> Printed nor <br /> II WORKERS'COMP'EMSATSOPI DECL ARA'"DN <br /> ' I hereby affirm under penalty of pejury one of the foflowkV dec1W`e1i11"9: (CHECK ALL THAT APPLY) <br /> I have and vAl maintain a ceffftate of oongemt to self-Insure for workers'compensation,as provided for by i <br /> Section 3700 of bre tabor Code,for the Performance Of the work for which this permit is isseed. !I <br /> I nave and WN maintain workers'COMpansau°n Insurance, as required by Section 3'100 of the Labor Code. <br /> Sar she pertomvtanoe of the work for which this permit is issued. My workers`Compensation Insurance <br /> carrier arrd e0 numbers are: n <br /> t�334— 01 a <br /> '� policy tiumber: <br /> I owtdythat in the performance of the work for which this permit fs laws <br /> i shah ,at employ any person in <br /> emy manner so as to became subject to the wnrkera'r�Per%zd n laws of CalTania and agree that N I <br /> DeCOfno slnbjecf ro the workers':mtnpettsabOshouid n prow siotts of <br /> 3,,,o of the Labor Code. I shad {4 <br /> forthwith comply w3h those provisians. <br /> Oats. Sfgmaure. <br /> Printed Mame: t <br /> WAR6it'tG:FAILURE TO SF.Ct1RE WORKERS'COUPENSATIOm(AVERAGE IS UX AWFUL.AND SMALL SUBJECT <br /> SAND <br /> AN EMPLO A OOOCRUAITIM 7NO PENALTi O AND <br /> DAVM L:ATSflN,ItdTFREST,ATTOO RKEY'�EES,AND AAMR <br /> F- AGES AS l� <br /> (Sf 00,000.), <br /> PROyioM FOR 1N GEC'n0N 3 nd OF THE LABOR CODE. 4 <br /> crc?!M-sed aurnorizedrepresentati+rel, 1 <br /> L' f i z J';.! 4 <br /> lerTheriae(prfM narr.r:} - <br /> to ago rhf%Sam.joagwm co nW well Permit Appl'icatiOn On my behalf. I undesaLand this autlrwl>tatiOe is valid(m <br /> IOno(1}yew and t6 Iii"o to the worn plan dated on The front Page of tnls al'PficadOn. <br />