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AUG-24-2004 TUE 04: 16 PM LTE & ASSOCIATES FAX N0*6 641 9222 P, 03 <br /> /,WJz r 3 i CFL. <br /> Son Joaquin County mrirenmental Health Department Unit tv Well permR Application Supplement <br /> JOB ADDRESS: -%56. N 4,1eL4,, 1'5W PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chaptar 9 (commencing with Section 7000)of Division <br /> 3 Otto Business and Profesalons Code and my license Is In null force and efrect. <br /> License#: 512268 Expiration Date:_d/30/05 <br /> uate: 1 tJ Contras r, Pam ,M Exploration, ins <br /> Signature- Title[_Operations <br /> ManaOar <br /> Printed name: Brenda Crawford <br /> WOWERSr COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I h111re entl will maintain a certificate of cement to ellfinDure for workers'compensation,as provided for <br /> by Section 3700 of tho Labor Code,for the performance of the work for which thia permit is leaued. <br /> .X—I have and w111 maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the pertormanee of the work for whtcfi mis permit IS Issued, My workers' compensation Insurance <br /> carrier antl policy number--qrw <br /> CAr ier National Union Fire Insurance Co. Policy Number: 8498303 <br /> I 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 anrkers'compensation laws of California, and Agree that if 1 <br /> should become subject to the workers'wrnponsation provisions of Section 3700 of the Labor Code, I shell <br /> fotthwith comply with those provisions, <br /> Date: Signature! <br /> v <br /> Printed Name: Brenda Crawford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATICIN COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,0003, IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDFn FOR IN SECTION 311'US OF THE LABOR CODE, <br /> RIZATI_ON FOR -- THAN C-67 SIGNING PERMIT APPL.ICATIoN <br /> t,_0rc 1 a"4xploratlon,Inc._(ciertature uM-07 licensed authorized tepresantatrw)) <br /> hereby auttwice 1print hamb)A i �­ IIIW"X— it- 1, no i k &:spud a*s <br /> to sign this San Joaquin county wolf Permit Application on my behalf, 1 understand this auehon2Ation is valid for <br /> one(1)Ysar and is limited W the work pion dated on the front page of arlu appULlUun, <br /> 9,2"21 MI <br />