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11/05/20_03 16:28 2095224227 GEOLOGICAL TECHNICS <br />AUG 22 2003 11 :43AM HP LASERJET 3200(;�-uta WUAL ILUIN11'' <br />8¢12212093 11:38 2095224227 <br />Y <br />San Joaqulrti County Envlronrttght>rl.tleaun <br />J1013- ADDRESS=�09f -x <br />o N - 2�1(44 <br />IV W�tl; .unit+gi5f(a,�tbn s <br />LICENSED CONTRACTORS DECLARATION (=) <br />I hgraby affirm that ► am licensed under the provisions of Cnapter 6 �aommencing with Se6om 7000) of Cllvlston <br />3 of the Susinesa and Professions Code and my IicBnse is in tuil force and effect. <br />trnl0 �+ EXDkaVon Cale: <br />Dato',� � ���tL'' Contractor. � • ff <br />Titls; <br />Signature: . , , _ __ . t <br />PAnted name' <br />WORKERS' COMPENSATION t)EdL-ARA71ON <br />PtGE 03 <br />P. r_ <br />I hereby affirm under penalty of perjury or,e of the foilowlna decfaratlgns: (CHECK ALL THAT APPLY) <br />jon. as <br />I have and vwili msinftln Codeir <br />, for the pe�o man,a�of `tis ork fo)Oufe for r which this party s Isauedvided Sot by l <br />Scotto n 3700 of th <br />ave and will maintain workers' C0Mp4tnsaVon Insurance, as required by <br />Section <br />3701 oath su eco Labr <br />ce <br />for the Periorm>af+odo <br />re bE the work for wh.ch this permit Is issued. MY <br />Carrier and policy nurnt�crs are ! rJ <br />r-y-� Policy Number: <br />Carrier: <br />GCrlify that In tme performance of the Work for which this oerrnit',6 is3ued; I ahaN not errtplay any person in , <br />any manner so at+ to becom e worksrsSUbjerl �cofnp nsat on prov s ons of se tan 3700 or'ne Lab the workers' compenaabon la � of Califorlia, and 9rCode. 1ee that 1611RI <br />should become sub)ect to <br />forthw <br />ith COMPiy Wein those Provisions, <br />Date: <br />Printed Nams; "E <br />WARNING:ON <br />PMrLOYER TO CRM NAL PP-NAOTIES AND CIV L FINES EI COVERAGE L16J7GT <br />UP TO ONE HUNGRRE.D THOUSAND VO ARS <br />IN ADDITION 10 TVIF_ r.OST OF N <br />PSRrJVIDrIi FOR N 3 GT10N X70 OF THe LABOR CODE. INTEREST, ATTORNEY'S FEES, AND DAMAGES A <br />_(G-67 Uwnaed authvfized repm"f ative), hereby <br />autherfss <br />to bign Nip gill ,l�quin County Yiletl Permit App nation ori any bet7al% I understand this authorization to valid for . <br />Ann rpt vaer and is flrnitad. to the work plan dated vn the fron! "rage of this sp Ilcatiorr. <br />h0dA WdLE:E 6661 -5z -0I <br />E 'd <br />