Laserfiche WebLink
12/16/2002 14 31 2094558773 <br /> SPECTRUM! EXPLORATION PAGE 01 <br /> San Joaquin County Environmental Health Services, Unit IV Wel! Permit Application Supplement <br /> JOB ADDRESS: 1876 C�.6 PERMIT SRS" <br /> SV,:"k;WP - <br /> LICENSED CONTRACTORS DECLARATION WC-D) <br /> I hereby affirm that 1 am licensed under the pravlsions of Chapter 9 (commencing wAth Section 7000 of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License#. 612268 Expiration Date ___X00103. <br /> Date — �fj Contractor Spectrum Exploration, Inc. <br /> 1 _ Title: Operations Manager <br /> Signature- <br /> Printed name: _Brenda Crawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> n <br /> I have and veil maintain a certificate of consent to self-insure for workers' compe sation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for vrhich this permit is issued i <br /> tt I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> r for the performance of the work for which this permit is issued My workers' compensation insurance <br /> carrier and policy numbers are <br /> Carrier,American Motorist_ Policy Number 3�G035T3800 <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 vmrkers'compensatlon taws of cairfomia, and agree that 01 <br /> should become subject to the workers'compens4Crr-a <br /> s of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Date. /.2 -/P—p Signature, <br /> Printed Name: Bre <br /> WARNING, FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL suBJECT l <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000),IN ADDITIONFOMPSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR NSECTION 3705 OF THEL CODE. <br /> 1,_Bmnda Crawford of Spectrum Exploration, Inc signature ofC-37 Incensed authorized representative), <br /> hereby authorize(print narne) C✓JGe"Ove <br /> to sign this San.Joaquin County Well Permit Application on my behalf I understand this authorization is valid for <br /> pRe (t)year and is limited to the work plan dated on the front page of this application <br /> 5.17�00fl f M! <br />