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03/31/2003 13:29 209465 73 _cPECTRUM DTVVATICN PAGE 01 <br /> r j <br /> 11 <br /> San Joaquin County @trvironniMiAl Health DNm�nl Unit I 11 V tMaM P*M*AppftmdD r SuPP M <br /> JOB AWRESS:�t^� Cc�R-rJ�R fie F "_� �PERMR SRS: <br /> LICENSED CONTRACTORS DECLARATION fLCD1 <br /> I heaeb)I affirm gut I am licensed under the provisions of Chapter 9(carrrriendng with Section MW)Of Mision <br /> 3 of Vie Badness and Professions Code and my 6cenae is in full torte and anted. <br /> Lksertaa or <br /> 612868 Expo Date: s <br /> 5 51 03 Centrads n ExPloNn,lea <br /> Title: OParatlom MamSa►_— <br /> Slgnature: <br /> Printed name: Brands Crawford <br /> WORKERS' COMPENSATION DECLARATION <br /> herebyahhm warder perjury One of the followI g dedwatwns: (CHECK ONE) <br /> romilded <br /> I haire and vA maintain a owpicate d consent t0 sel"o ral 'which .s forr by Section 3700 of the Labor Code,for the perfomrance tlie <br /> �( I have and will mdntain wakm,cainpensOficn insurance, m required by Sedkm 3710 of the Labor Coda, <br /> for the pedonrowe of go work for which this PaMA is Issued. W wwkeW coITOWARdon insurW"' <br /> carrier and policy nranbom are: <br /> Carrier: Lumbarman's Mutual Panay Number. 313&76432101 <br /> 1 tangly that in the perfom+anca d the work far which this pwn*is Wsued, l shall not arnplay any person In <br /> marm so as to beaorne subject to e workers cmnpara9a W laws Of Cal6om'A and agree <br /> soth <br /> uld bacon.m4ed to the workeW oomperostiOn of Section 3700 of Urs labor Code. I shall <br /> fodirm th campy with those provisions. <br /> Date: 31 Sf 103 slgnsbm <br /> Printed Name:!Blends Crawford s <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNI AWFUL <br /> t19FU -AND SHALL SUBJECT <br /> AN 191APLOYER TO CRIMINAL PENALTIEs AND CML FIMS UP TO ONE 11101 HUNDRED "Np DOLLARS <br /> (N00AOLI IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY`S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5706 OF THE LABOR CODE. <br /> AUT RIZATION FOR 0 THAN C-87 SIGNING PERMIT APPLICATION <br /> I. Ord,of spectrran FkPlorslfor4 Mo,_jsipnators 0110-V licensed authorreP ). <br /> ized esoM1#v <br /> herby auvwto(pint rams) <br /> 40 sign this sae Joaquin Cow*Well Penult Applioavon on my behalf. I undweland 9110 suthonb2tblid u Is vafor <br /> one(1)year and is Ilmited to the work plan dated on Ulu front Pape of Ib10 applieatloe. <br /> 1.M42 IN <br />