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,••_. .,.. .,� acs:csa apecrrum txp. 209-485 -8773 P. 2 <br /> :I <br /> r <br /> San Joaquin County Environnwntal Hedth Services,_UOR iXl Willi POMIE Apokathn t3epptstrrsnt <br /> JOS ADDRESS, 'th la k- d PERMIT SRO.- <br /> LICENSEd CONTRACTORS DECLARATION i(LC <br /> I hereby I am awaarread under the provisions of Chapter 9(porn encing with Sewn 700.0)cri OrESIca► <br /> 3 of the mess and Pr6Nesjorts Cede and my Imme Is in full for+Ca atxt t�sc�; <br /> C570 .5 F.xpir an a 0413012003 <br /> Dade: /" 0—dV""" C.OrtlTacjw Sge rtlm A3RIgratiqe, Thq., <br /> Tile: t tdera ion age <br /> s Man <br /> PrIated narnw. Brend rB!fgrd <br /> WORKERS*COTAPENSAT"IDE04AWION <br /> hereby aftn under penalty of pejuly one of the kd0WrQ `orrsi (HECK ALL THAT,APPLY) t <br /> I <br /> i halir@and will niWntain a: of oWeef t to sat 4 e fOr workers'cOmpensalaon, provided for by <br /> Ser*3700 of the Labor Code,for the performance ofOwwank for wimch this permit is issued: <br /> I have and wE ma'sntain work c�otnpWMWM in ranee,as valued byS 3 ;ar the Labor Coda, <br /> for tine perfom nee of the work for rahlch this peanit is issued.. My wodwrs'=npentsad orr Imurance <br /> r anti lad icy numbers are. <br /> i <br /> American Motorist Po&cy 1jUtntter: 3BG03575 t}(} <br /> t*ortit'y that in the performance of ft vxrk for v ch this Perrot is issued,l SWI not smPloy any person in <br /> any nWww so s to become suNect to the workers'CWWWhmof Caffornia,;and agree that W I F <br /> Should bworne subiW to the workers'cvmparssatlon p ions of Section 3700 of the Labor Code,,I SWI <br /> fortttvvlth cmptyvrith those provisions. <br />! Ptad Nam: <br /> Brenda -ClAtoford <br /> ►_ :,- ;,�':.� `WARNING:-FAILr1rlE.TO SECURE VI ORKERV'com eAlh W COVERAGE IS UNLAWFUL,AN �r�r <br /> .D SHALL ECT <br /> AN EMPLOYESTCI CR11 INAL PtNALTIES AND CIVIL Akti•t1i VTOONE HUNDRED THOUSAND DOLLAR <br /> r (siooxo IN ADDITION TO THE COST OF COMPENSATIOlk.WTEREST,ATToftNEWS FEES,X►ND DAI"ES:AS <br /> PROVID MgINI SE+C'TiGM 3706 OF THE LABOR CODE. <br /> It Brenda 'CrawfOrd. of .Spectrum E..xplor.(signature rt*IC41 licensed authoeiwd rep"wenhlf►P), <br /> 1 <br /> I to sign tMs Saa Joaquin County Well PSMIt APptl"dat tNtMy baud i 0nderstand Ns authorindlon Is valid for <br /> i <br /> ono('I)year and is limEtad to,0 icor*p als tH�# I Crn *Out PNP of this applis awn. <br /> 1 6474MIM1 n. <br /> r r. <br /> I <br /> f(t <br /> i st. a <br /> S <br /> { <br /> i <br />