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Ipuri t, tWLUKATION PAGE 81 <br /> 0 <br /> F-li- <br /> a JQagUIn County Environrnerttal Health Department Unit IV Well Per7nR Application Supplement <br /> JOS ADDRESS: ► i7u� �ERIYIIT <br /> LICE SED CONTRACTORS DECLARATION LCD <br /> I hemby of rin that I am licenced under the provisions of Chapter g(commencing with Section 7000)of Division <br /> 3 of the Business and Pmfessiohs Code and my Iiconse is in full force and effect. <br /> License*: 31h8 Expiration Date: X0105 <br /> Date; q L110 1 d Contractor:�Spftftm explo"M01%km <br /> SiVatM: Tice. 0pemilons Manager <br /> PrInbed name; Grencla l�rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> hemby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a cettificato of consent to self-Inme for MfO tcers'compensation,as provided for <br /> by Section 3700 of the Labor fie,for the performance of the work for which this permit is issued. <br /> ..(,, i haedon <br /> for w and pertb arm na of for ha the 1 own isice� -1 woortIred e by <br /> compensation��mnoo de, <br /> carrier and policy numbers are; <br /> Carrier: National Union Fire Insuranco Co,_ _ Policy Number.SQSM- <br /> I cel*that in the performance of the work icor 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 Cal'rfomia,and agree that if i <br /> should beCome subjed to the woftrs'wmpensaWn provisions of Secton 3700 of the Labor Code, I shall <br /> forthwith comply witri those provisions.. <br /> Date: 1[D_ Signature. <br /> Printed Name:__8rehda Crswford <br /> WI IRNING:FAILURE To SECI)RE W0RKrnRS'COMl3ENSA'n0N COVERAGE IS UNLAWFUL.AND SHX.L SUBJECT <br /> M EMPLOYER TO GRtMiNAL PENALTIES AND CIVIL.FINE$ UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ('ou j)o0.),fel ADDITION TO THE COST OF COMPENSATION,INTEREST,A1TORNEy1 S FEVS,AND DAMAGES AS <br /> PF;OIIIDED FOR IN SE"ON 8708 OF TF{F-LA80R CODE. <br /> ZCR14TION FOR OTHEJ4'i TAN C-57 SiONINO PERMIT APPLICATION <br /> ff,at'Spectrum Ex;Aoration,Inc.(s+gnatz r ofC-.►`7 Ilrrehsed authostized rg+Rrosgrrtative}, <br /> l>f dre by authorize(print name) k .. c U <br /> tc sign this San JWulo County Well Permit Appl;catlnh bn my behalf_ I understand this authorization i�valid fw <br /> one I71 year and 6(iml6ad t4 the work plan dutud on the Front page of thin applicAttaan, <br /> 8-29-D7 f Ml <br /> r <br /> Z 'd LTOT a9S LDL UWUIS I ANUW -11 I H WeH3 Je T :EO SO Go qa_A <br />