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04/30/2004 13:30 20952"4227 GEOLOGICAL TF" 4NICS PAGE 02 <br /> \ftwl lids 003 <br /> 8ttr5.ln7aqufl� Covntyr'�vironlnentel tirzalth l3$tvioe�,Untt.iV Ulter11-Parm4t•App11e2ficn Supplement <br /> JQB ADDRESS: 5 l W_ Lu�A � PE.RMW Sku, <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that t am licensed under the provi 3iQns Of Chapter 9 (camrrmcnding with Section 7000)cf Division <br /> 3 of the Buslnesss and Professions Code and my lipense.is in full force and effort. <br /> License#: �C4 NO L/ _Expiration Deto: t� <br /> Date: ctor: <br /> Signature:. Title: <br /> Printed risme: <br /> WORKERS'COMPENSATION DECLARAPON <br /> h"by aMrm unclasr pen My,of pequry one of the followlrij?declorations; (GHi`CK ALL THAT APPLY) <br /> mwo and will maintain a certificate of consent to self-insure for workers' compensation,as provided for ny <br /> Sectlon 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> ✓ I have and will mainfaln workers'compensati*n insurance, as requires!by Section 3700 of the Labor Code, <br /> .�for the perfcirmance of the work far which this permit is Issued. My workers'compensation insurance <br /> cmrner and poiicy numbrers are: { <br /> Carrier-_ IF Policy Number, 57 ,5 � �"a <br /> I certify than In the performance of the work for which this permit is issuad, I sh®II not employ'atly person in <br /> '+any mannar so ea to beoorne suWect to the workers' compensation laws of California, and agree that If 1 . <br /> should becoma subject to the workers'compensation provl8slons of Srtion 370D of the tabor Code, I shall <br /> forthwith comply with those provisions. ! I <br /> Da e• 14 ^3 U - — -Signature,—.. l_ r ' —--- <br /> t <br /> 4 <br /> Printed Name: �l. ----�— <br /> WARNING:FAILURE To 3ECURL_WORKERS't_0MPt~NSATION COVERAGE IS UNLAWFUL,AND SHALL SU11JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANIS CIVIL FINES UP TO QNE HUNDRED THOUSAND DOLLARS <br /> (SID0,00j,Its ADDIT)ON TO THE COST OF COMPGNSATIQN, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROMED FOR IN SLCTjON x7'06 OF THF LAE30R CODE. <br /> 10-57 licensed authorleed representative), hereby <br /> 13u41•rorize 1�°may Y��'`d� ,,. `�-�^�A'Yti�yd _ .,, � — -- ., , ...— <br /> to&Iqn this gan Joaquin County Wail PermitApptiaaatioh an my behalf. I undramtand this authorization is valid fos <br /> aria(1 yegr and is iimlteci to the work plan dated pn the front Pac9+a of thio® libation. <br />