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P AA' S /2Dt.1/ <br /> El <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: A � PERMIT SR#: <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 i <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: c)1 2268 Expiration ate: 4-30-07 <br /> Date: Contractor: Spec rum Ex loration Inc. <br /> i <br /> Signature: Title: Location Manager <br /> Printed name: Brenda Crawford <br /> WORKERS' COMPENSATIO DECLARATION <br /> F <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> E <br /> _I have and will maintain a certificate of consent to self-ins re for workerscompensation, as provided for <br /> L by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X 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 /> E? carrier and policy numbers are: <br /> National Union Fire Policy umber: 717 1494 <br /> Carrier: y <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> 7i&,Ai.L—� <br /> Expiration Date: 4-01 -07 Signature: <br /> Printed Name: Brenda Zrawford <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 G (signature ofC-55y7�licensed <br /> authorized representative), <br /> hereby authorize(print name) L G G�� , � ww/ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5-29-02!Ml <br /> [HD 29-02-001 <br /> 6/22!04 <br />