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11/05/2003 16:25 2095220-7 GEOLOGICAL TECV--CS PAGE 03 <br /> e. <br /> [I1U- ut <br /> AUG 22 2003 11:4 209522 22 HSERJET 32000 ULUI�JI;flL ILUINi�a <br /> B4} 2212003 12:3a <br /> Y <br /> � t;�► .le#I�bh:BuPp�srnen <br /> Ft <br /> Cpur+tY Lrnv;�„ dhpr4.11salth ew cola,usi.1116 Wri - <br /> s; o LICENSED CONTRACTORS DECLARATIONt 1 am lloehsad under ne provisions Pf Chapter 9(pomm8tlClnp wth SecHan 7f>DO)of f]Ivlston <br /> and professbne Code and my license Is in lull farce and®erect, <br /> IJCYgbe#: � (_�plratron Dete: <br /> T]9tY;v t Conft tar: <br /> Sipnattu Tit1b; <br /> rs: <br /> WORKERS,COMPENSATION DECLARATION <br /> 1 hereby l3tfirrri under penalty of perjury one of the following declarations: (CN1C4C ALL THAT APPLY) <br /> on,as <br /> hav9�37DOIotth4tLslsor Code,for hperforrnesent to nca�of Srg work forwhworkers! <br /> 1ph this pa mtit s Issued lar by <br /> ZI <br /> $CGfor#1e and <br /> rlrnano(ain of tha work focrwhlch thuiOn s permit Insurance,ensued required <br /> workers`compensation in$urancSection 1700 of the Labor Code. <br /> Carrier and policy humbors are, <br /> Carrier. ' Policy Numbsr: .� y <br /> csMiry that In the perkrinance 01 th®work for which this per•rnit is i530ed,I shall not ernploy any person in <br /> to become subject Io the workers'compensation laws of California,and agree that if I <br /> any manner so as <br /> should become swbJeGt to the worker�r'cvmpensatlon provlsloris of Section 3700 of the Labor Code, 16111611 <br /> forthwith oompiy win tho4e provwlons, <br /> Date* Q t ?_ ✓�i' Sl�q►tur■ <br /> printed Nave«: Q <br /> _~ 19 UtdLAWFUL,AND SHALL <br /> WARNING,FAILURE TO 811CURE WORK05'CCMPENSATIQN NflREO THOUSAND Cep ARSuaJECT <br /> AN 0VL0YElt To cRImINAkL PENALTM6 AHO CIVIL.FINES WP Tb ON HU <br /> PRQVQ00.),DRI)FIN AnDIOR N 3EI c[I'go THIE COST Of d10 of T►iC LABOR CODS ONS INTEREST,A(TORNEY'S F6E5.AND taAMAOcEs aS i <br /> 9antO �hereWey <br /> _(C-67 iiwnaed rruthvriz►d septa by <br /> ( <br /> ,uth�. .mss i <br /> to 09p thiw Than Joaquin County WHO P4rmit App ration on my behalf. I understand this authorization is vend For <br /> ons 7 ear err4 in Irrrdtad to the work Ian doted on the front POO!of this OPPliaatien _ <br /> �•a <br />