Laserfiche WebLink
06/02/2003 13:40 2094650773 SPECTRUM E>n-ORATION PAGE 03 <br /> San Joaquin County Environmental Health Department Unit 7N�We1 <br /> ��1 Permit Application Supplement <br /> JOB ADDRESS; J 9600 y,dEgSm+ MIT' SR#: <br /> ILICENSED CONTRACTORS DECLARATION (LP2) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8(oonvrwncinp with Section 7000)of Divlalon <br /> 1 3 of the Business and Professions Code ctrl my license to to full force and effect. <br /> CLicense R: 412268 - Explrstion Data._'M6W111' 4 Rd�0''-r-y--'— <br /> p 3 Contractor.Spectrum Exploration,Ina <br /> signature. Title: Operalfons Manager <br /> I <br /> Printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I boyo and will maintain a certificate d consent to pN-insure forworfuue'compensation,as providadtav <br /> by Section 3700 of tta Labor Code,for the perfarmarce of the watt for width this pemit is Issued. <br /> X_I have and NAI maintain workers'compensation insurance,as requited by Section 3700 of the Labs Code, <br /> for the perfornanoe of the work for which this permit Is Issued. My workers'compereatlon insurance <br /> i carrier and policy numbers are: <br /> Carrier._Lumberman's Mutual Policy Number:36A164321D1_, <br /> i I certify that in the performance of the work for which this permd Is issued.I shell not employ arty prison In <br /> any manner so as to beoarne subject to the workers'compensation laws of Califomia,and agree that If I <br /> should bacons subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> l rerilwft comply with those provisions. ( f <br /> Data, (PI P4 0 3 Signature.- l i <br /> Printed Name _Brenda Crawford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND 814ALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINE UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED IN <br /> N ADDITION <br /> DN ION TO THE <br /> N 3708 O ST O LABOR COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGE$AS <br /> ORIZATION FOR QTH�$THAN C-67 SIGNING PERMIT APPLICATION <br /> I,_e Wfard,or Speurun Expiwatlon,ine._(signsture ofC•57 ikw%W euthoriad representative), <br /> e'1.e c n 7 "Ctm 644M._�lt�4'h Tech <br /> hereby authorize(print reams) �YU l Yll Yl r 1 re <br /> to sign this San Joaquin County Well Penna Application on my behalf. 1 understand this authorization it valid for <br /> ares(1)yew and is limited to the work plan dated on the from Page Of this SPpiioatbn. <br /> 8.24421 MI <br />