Laserfiche WebLink
SPECTRUM EXPLORATION rAu <br /> 02/10/2003 14: 38_ 2094658779 <br /> t uc <br /> d1� I/u/�}5 `7J Z <br /> Supplement <br /> > nvlronmental Health Department Unit 1V Well permit Application Supp <br /> San Joaquin County PERMIT SR#: 32 �3 <br /> JOB ADDRESS: 7/a X c <br /> LICENSED CONTRACTORS DECLARATION (LC )) <br /> I hereby that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and 03 <br /> License#: <br /> 572268 Expiration Date: <br /> Date: <br /> 1 D C ntractOT-- –Spectrum Exploration,Inc. <br /> Title: .Operations Manager__ — <br /> Signature: <br /> anage __ — <br /> Signature: <br /> Printed name. Brenda Crawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally of perjury one of the following dedaratlons: (CHECK ONE) <br /> of <br /> a certificate of consent to self-insure for workers'comPe"s2 I s i provided for <br /> by Section ill of the Labor Code,for the performance of the work for which this permit is ssued• <br /> I have and will <br /> I have and will maintain workers' compensation insurance, as required by Section of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'cpmpensatlon insurance <br /> sat <br /> carrier and policy numbers are: <br /> Carrier: Lumberman's Mutual Policy Numbec 3BA1G432107_ <br /> i certify that in the performance of the work for which this pemrit is issued, I shall not employ arty Perron in <br /> any manner so as to become subject to the yyoro co sites of Section on laws Of 3700 of the I aboria and rCode, lI if <br /> should become subject to the workers' comp P <br /> forthwith comply with those provisions. <br /> Data: 2 D 03 Signature: -- <br /> Printed Name: Brenda Crawford <br /> AND SHALL <br /> AWARNING: FAILURE TO SECURE N EMPLOYER TO CRIMINAL PENALTIES WORKERS'UBJECT <br /> ND CIVIL FINES UP TO ONE HUNDRED HOUSAND DOLLARS <br /> ($700,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR I SECTION 3706 OF THE LABOR CODE. <br /> �IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> _g Cr rd,of Spectrum Exploration,inc._jsignature ofC-67 licensed authorized representatlys), <br /> hereby authorize(print name) <br /> ih L-5 ' tt 1 ' n 1 <br /> to sign this San Joaquin County Wall Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br />