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.. <br /> 20,^4465-8773 P• <br /> Aug 05 02 11 : 09a Spm_ Crum Exp. (`JI <br /> i <br /> i <br /> I <br /> li-alion Supplement <br /> San Joaquin County Environmental Health Services,Unit IV Well Parrott App 3aS <br /> �� pAM� P lent 33 PERMIT SR#: 08 <br /> JOB ADDRESS. Qfi <br /> LICENSED CONTRACTORS DECLARAMN (LCD) <br /> 1 hereby <br /> affirm that 1 am licensed under the provisions of chapter 9(commencing Will Section 7000)of Division <br /> ' 3 d the Business and Professions Coda and my License is In full force and effect- <br /> License <br /> 04/30/2003r---- <br /> E <br /> /30/200 3 <br /> Ucense# <br /> C57# 512268 Expiration Date: <br /> Date: <br /> contractor. S ectrum Ex loration Inc. <br /> Tide: Operations Manager I <br /> Signature' <br /> ' <br /> Brenda rawford Printed V <br /> WORKERS' COMPENSATION DECLARATION I! <br /> 1 hereby affirm under penalty of pe0ury one of the following declarations: (CHECK ALL THAT APPLY) <br /> compensation, as provided for by <br /> _I have and will maintain a certificate of consentdormance-I the woselrk for which thispermit is issued. <br /> Section 3700 of the Labor Code,for the pe <br /> XX <br /> 700 of the Labor Cade, <br /> 1 have and will maintain workers' compensation insurance, as required by Section 3 <br /> for the performance of the work for which this permit is issued. My workers compensation insurance <br /> carrier end policy numbers are: <br /> bar, 3BG03575800 <br /> Carrier. American Motorist Policy Num <br /> 1 certify that in the performance of the work for which this permit is Issued. I shall not employ any Person in <br /> ron laws of California,and agree that if 1 <br /> any manner so as to become subject to the workers'compensation <br /> should become subject to the workers'compensation pro ons of Section 3700 of the Labor Code, I shall <br /> m <br /> forthwith comply with those provisions. <br /> Data: ;L_ signature: <br /> Printed Name: Brenda C wford <br /> J7 i <br /> SHALL <br /> 1 AN EMPLOYER FAILURE CRM HAL PE WORKERS' <br /> HUNDRED THOUSAND <br /> AND CML FINES UP TO ONE AND <br /> DOLLARSUBJEC <br /> 1 i ($ioo,0 .),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> 00 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> s$ " <br /> r (sinaturo otC-67 i'c^ensed <br /> Brenda Crawford of horized representativel• <br /> y I Spectrum Explorg <br /> . <br /> 3..,n <br /> 12 <br /> IIt,S 0 <br /> f� herebyauthorize(printname) <br /> " Application on my behalf. I understand this author[ <br /> tosign this zation Is valla for <br /> 'k , San Joaquin County Well Permit <br /> 'px''• r,rt r•i, <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> °-f 577-20001 MI t. <br /> F ' <br /> 1�f'�yg <br />