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M-I�j 30 02 03: 21p Spectrum Exp. 209-465-8773 p - z . <br /> San Joaquin County Environmental Health Services, Unit W Well PQrmit Application Supplamert <br /> JOB ADDRESS: Q.��, PERMIT SR#:_ O 030 o <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> " I hereby 81%rnl UvA I am licensed under the provisions of Chapter 8(commencing with Sem.1ion 7000) of Division <br /> 3 or the Business acrd Professions Code and my Ncense is In full force and effect <br /> j l_laer>9e V. C 5 7 q 512268 Expiration Date: 04/30/2003 <br /> Date: 5�,30/Da' Conlrador Spectrum Expl.ornc. <br /> i Sign ~� Title, Operations Manager <br /> Prince name: Brenda rawford <br /> t <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby atfkm under penalty of perjury one of the following dedarations: (CHECK ALL THAT APPLY) <br /> I Rave wA wtll maintain a certificate of consent to self-irmure for wortcers'compensation, as provided for by <br /> SeCOW 3700 of the Labor Code,for the performanoe of the work for which this permit is Issued- <br /> XX-I have erhd will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the perfomhance of the work for which this pyarmlt is issued. My workers' compensation Insurance <br /> carrier and policy numbers are: <br /> !i Carrier, American Motorist Policy Number. 3BG03575800 <br /> t certify that in the perfo rnance of the work for which this pen-nit is issued, 1 shall not employ any person In <br /> any manner so as to become subje.4 to the workers' compensafion laws of California, and agree that if I <br /> should become subject to the workkeW compensation pr0V ,f Section 3700 of the Labor Code, I shall <br /> foftfrwith cm*with those pro+iisiorts. <br /> Data; Jam/ 3410 — <br /> --Signature.• 1- <br /> Printed Name: Brenda C wford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLA1NFUL,AND SHALL SUBJECT <br /> AN EXPLOYER TO CPWAINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,004.),IN ADDITIJN TO THE COST OF COMPENSATION,INTEREST,ATTtORNEY'S FEES,AND DAMAGES AS <br /> DED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> h,'Brenda Crawford of Spectrum Explor..(�Ignaturs ofC�--57 lizensed authortzed reprosentitwe), <br /> hareb wenorizs(print name)�',LLT/, <br /> to sigh No San Joaquin County Well Permit Application on my behalf, I understand tMe authorization h valid for <br /> :•'R' oNi(1)your and Is limited to the work plan dated on the front page of this application. <br /> -Y 5-17-2M I MI <br /> .J"" 7 rn <br />