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Feb 26 01 03: 41p SF"',�trum Exploration, Inc 20F A65-8773 p. 2 <br /> UZI[b/GUU1 1:J.1:J �U'7µGiS N�� r lr III r,uum NOW/ H L uv <br /> [ San Joaquin County Environmental Health Services.Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: I rlSs � � 1ST PERMIT SR#: DD h 5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#:5— Expiration Date: J a <br /> Date: <br /> Contracto. <br /> Signature <br /> Title: ^� <br /> Printed name: 422 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> —Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance.as required by Section 3700 of the Labor Code. <br /> —for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> �1d policyNumber: <br /> Carrier Gv <br /> I certify that In the performance of the work for which this permit is issued,I shall not employ any person in <br /> compensatlolaws of California, agree <br /> f I <br /> any manner so as toect to he workers'compensation provtsionsbecome subject to the workers' t Section 3700 ofthe LaborCode, I Ishall <br /> should become subs <br /> forthwith comply with those provisions. - <br /> Date:__._�— Q 0 �Signature: <br /> Printed Name: 0� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, <br /> AND SHALL SUBJECT <br /> AN EMPLOYER TO CRI To THCOLTIES AND ST O COMPEIL FINES Up TO ONE HUNDRED THOUil)DOLLARS <br /> NSATION INTEREST,ATTORNEY'S EES,AND DAMAGES AS <br /> ($j 00.00t).),1N ADDITION <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> cG !!m .- (C-S7 licensed authorized represenlative),hereby <br /> 1, d . <br /> authorize <br /> Application on my behalf. 1 understand this authorization Is valid or <br /> to sign this San Joaquin County Wall Permit App� I�cation. <br /> one(1)year and is limited to the work plan dated on the front page of this app <br /> 5.17-2000 J MI <br />