Laserfiche WebLink
01/14/2008 17:14 209465877' SPECTRUM EXPLORATION PAGE 01 <br /> San Joaquin County Environmental <br /> Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: '0 lot N M'tA1'1 kt� 'FERMIT SR#: <br /> i <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I 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 effect. <br /> License* 636387 Expiration Date: 1 /31 /2010 <br /> Date: r09 Contractor: Precision Sampling, Inc. <br /> Signature: Title: Location Manager__ <br /> Printed name:_ Brenda Cr wford <br /> i <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> X I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> CarrierLiberty Mutual Insurance Policy Number:WC1 671072339027 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> i <br /> Expiration Dat®; 6/3 0/2 0 0 8 Signature: <br /> Printed Name: Brenda Crawford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSA11ON, INTEREST,ATTORNEYS FEES,AND DAMAGES AS i <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 Ilcensed authorized representative), <br /> hereby authorize(prtin!name) , <br /> to sign this San Joaquin County Well 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 1 MI <br /> OID 29.02.001 <br /> W2 2M <br />