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01/21/2005 10:47 9167867891 ENGEO INCORPORATED PAGE 62/94 <br /> 01/21/2005 FRI 10:10 FAX ` 2002 <br /> 1.'7%'1hi:'Gti.Q frc:.:.'I `31.1:5511 ' <br /> San Joagt(In Douoty Enviroemvatal Hraith Depurtment UnitIV Weir Permit Appfiea:ion Supplement <br /> JOB ADDRFSS:• PERMIT SR#:" , <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby afflRT that I am licensed under the pmvl&lens of Chapters(Corrimendrfq with 9oetieh T 000)of Diviaipn <br /> 3 of the Business 2rd PreIPA91 ns Code and my lioanan 18 In full to R'0 and 4frect <br /> License it; P,0 ,. PLiamillCCrate1: �` <br /> Dater Oontra or: W Jit <br /> 9lpnature: `r 11t1a: <br /> printed naine ..__.f- - - <br /> WORKP-RS' COMPENSAT DISCIARATION <br /> I hereby affirm unCvr penerty of pertury one of the tonowinq dcplar3ticw (CHECK ONE) <br /> I <br /> I hays anvil will maintain a eartif ante of C*n3entto sdsure!-inforworkara'componsatlan,as provinntl rot <br /> by Secdon 37UD of the Lahor Cade,for the performance of the work far whit':this f+emvl is il:sund <br /> I have aril will maiNsir wodtars' ownponsetion Inburancer, ne requlrad by Section 3700 Or the Lohni-Cod <br /> fc'Uta pilejar eenco of the worn forwhicn this permit i4 iaswed, My worker..,e cvmpeneaWn Insurance <br /> Canter err rolicy nultlhejtiS are; <br /> -� � I a' <br /> a <br /> Pollry Number: �.—. <br /> I csr*thief in the perfonnanco of the work for wr k'h this pormlt is issued,i anRII not employ any person In <br /> any manner so as to bocotne cubjeat to the workers'CCmpeneation kkwa of Califoril rind earce that if i <br /> should J*wril sill to the workers'compansa on prmfisions of on 3700 of the Labor Code,I shall <br /> kh <br /> forthwdamplywinthoae pwsio it. <br /> Y <br /> Date!„ _ signature: <br /> ;r <br /> Printed Name. - --- <br /> WARNING:PA!LURE TO SGCURE WORKERS'COMPENSATION COYERAOE IS UNLAWPUL, D SMALLSUBJECT <br /> AN amps OyaA To cWaallAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED TltouSAND DOLLARS <br /> ($100 DEO IN FOR N I'7lOSCOIN IQ HE CST OF <br /> TMS LABOR COMPENSATION,INTEREST,ATTORNEY'S FEES,AND OAIMAD6lt AE <br /> THORIZATIO FOR OTHER THAN C-57 SIGNING loMMIT APPLICATION <br /> Z � 4r^�' .. Ielgnatum efC47 fteneed a'i£herixad representative), <br /> to Slpn this BaA JDequla C04aly Well F•efTrfif Appeeaf<en en my behalf. I understand this AdUloririsden'r]"lid for <br /> one(T)year and is limited to the work plan d,tarf on the front page of this epnlkliti <br /> .,. . :' L1 <br />