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�p�ctrum Exp. - <br /> • 20Q-465-8773 <br /> P. 2 <br /> V.r <br /> Sar!Jmq <br /> asih County Eneiironrrrental HOetth$oroiCess U tin N IPi1eIt Penn Appl .,Suppt flnem t <br /> JOB ADDRESS; 5jj X77 Ct�'l' <br /> PERZIT SFW: <br /> C`j <br /> LICENSED CONTRACTORS DECLARATION !.CD <br /> l hereby affirm that t sm licensed under theP ions of Ch <br /> 3 ofthe Business and Professions Code a Cha 9(arcing with Section 7000)of Qivislon <br /> my cense is In full force and effect. <br /> Licenss a C57# 512 2 6 8 Expiration Date: 0 4/3 0/2 0 0 3 <br /> Da+e: Q �� Lrawf=ord <br /> ractor: Spectrum Exploration, Inc <br /> Slgri�-turQ: �_ <br /> Tido: Operations Manager <br /> Prim nar,-7 Brenda <br /> UVORKERS'COMPENSATION DECLARATION <br /> 1 hereby eftirm under Penalty of Perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and till maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the psrfflrnmirm of the work far which this permit is issued. <br /> I have and will maintain workers'compensation ompsnsaition insurance,as required by Section 37M of the Labor Gode, <br /> for the pmfonnance of the work far wh.Ich this pea'mit is issued. My Markers'compensation insurance <br /> carder and policy numbers are: <br /> Carder: American Motorist Policy tiumbor.. 3BG03575800 <br /> _t t:ertif}r that in the performance of the warts for which ttds permit is issued, 1 she[not employ sny person in <br /> any menner so as to become subject to the►corkers'compensation tams of California,and agree that if I <br /> should bac=e subject to the workers'compensation ompensaation prosy "ons of Section 3700 of the Labor Code, I shall <br /> fortlwith comply with those provisions. <br /> Mato: /O/A3161 d Signature: <br /> Printed Nam:.Brenda C wford <br /> WARNNIM:FAl6_URE TO SECURE WORKERS'COMPENSATION COVERAGE IS UMLAWFUL, AND SHALL SUBJECT <br /> All EMPLOYER TO CR='OMAL P1EPALTiES AND CIVIL FIM UP TO ODIE HUNDRED THOUSAND DOLLARS <br /> ($10,000.] IN AMMON TO THE COST OF CO:JPENSATION,IMTEREBT,ATTORNEY'S FEES,AND UALIAGES AS <br /> PROVWD FOR IN SECIMM 3706 OF THE LABOR CODE. <br /> , Brenda Crawford of Spectrum Explor•(signature otC-57 Iiconoed authorizod r'precentative), <br /> I1 � <br /> hsroby cutlmrizo(print name) <br /> (yn 6-C kound <br /> to c!gn tiro&,-n Joaquin County Well PcnWt Application on my behalf I understand this authorization is valid for <br /> ono(1)year and is Ilrn[fed to tho cork plain dated on the frond pcg3 of thla application. <br />