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03/26/2004 13: 49 2094658773 SPECTRUM EXPLORATION PAGE 02 <br /> 06/26/2004 14:20 FAX 209 948f, � SPRECTRUM Qitlo2 <br /> San Joaquin County Environmental Health Services, -- <br /> I-'nit IV Well Permit Applicatioll Supt�lF:IrFrt} <br /> JOB ADDRESS. S� <br /> PERMIT" SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chaptor 9 (commencing with Section 7000 OF r)ivisicnn <br /> 3 of the;Business and Professions Code and my license is in full force and effect, <br /> License#: � c� F_xpiration bate: <br /> pike Contractor: G►�—.� -._..._—.. ... <br /> Signature: <br /> --r Title: <br /> Printed name: <br /> Wo ERS' COMPENSATION DEc,LARA-rION <br /> I hereby affirm under penalty of perjury one of the following declaratiorls, (CHI=CK ALL THAT APPL-Y) <br /> I'have and will maintain a certificate of consent to self-insure for workers' compensation, K;,, >vu-i, ,.J`c:r Irr <br /> Section 3700 of the Labor Code, for the performance of the work For whicil this permit is i :-q lead. <br /> have and will maintain workers'compensadon insurance, as required by Section 3700 of th��: L..atyc�r C:ri; <br /> or the performance of the work for which this permit is issued. My workers' compr•n salion in,;Lir's)n;;(- <br /> - <br /> carrier and policy n 1r�re: //i� <br /> Carrier: n�_ t(4 1'19 C ® 6j� <br /> -•map „___l'elicy Number: C� <br /> I certify that in the performance of the work for which this permit is issued, l shall not employ any fi.�rson i,, <br /> any manner so as to become subject to the workers'compensation laws of Californi�, arld agrF,,�a I:hal if I <br /> should become subject to the workers'co nsation rovisions of Section 3700 of the Labor i3ode,, f iwhsll <br /> forthwith comply with thcse provisions, <br /> Date: � --� _Signature: - <br /> Printed Name: <br /> WARN F,AIt,URI TO SECURE WORKERS' COMPENSATION COVERAGE Is UNLAWFUL,AND SHALL;tlFl.Ir.�M 1 <br /> A PLO R TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND E)0La_.R`4RS <br /> 100,000.),l ADDITION TO TFIE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND D�`PAAGES AS <br /> ROVIDCD OR IN SECTION 37 OF HE LABOR CODE., <br /> i' (C-57 licensed authorized rPpr4,,! enUtiv,6), I- : <br /> authoriz <br /> to sign this San Joa i County Well Permit Application on my beha)f. I Understand this authoriz.7tion <br /> one(1)year and is kited tn the work plan dated on the front page of this application. <br /> 5-97-MooI Mi <br /> 03/26/2004 FRI 14:43 [TX/RX NO 92571 Q002 <br />