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Mar 13 O❑ 12: 14p Bre/Spectrum Exploration qua-moo.• •• <br /> San Joaquin County Environmental Health Sarricm,Unit IV Welt Permit Application Supplement <br /> JOB ADDRESS:, -FZ 1� V-L �2_ �� r PERMIT SRO. <br /> LICENSF-D CONTRACTORS DECLARATION CLCD <br /> I hereby affirm that I am licensed under the pravisiuos of Chapter 9(oomme3ncing with Section:70013)of Division I <br /> 3 of the Business:and Professions Cotte and my k**se is in futi force and eNect. <br /> Ltense 9 Z Expiration Date_ 101_ <br /> Date: 3 t 3 o Contrad or: <br /> signature: Title: <br /> Printed name: <br /> WOKKIERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certiticate of consent to selfoinsure for Wo ters'compensation,as provided for by , <br /> __..Se don 3700 of the Labor Code.for the perforawnce of the work for which this permnit is issued_ j <br /> 1!lave and wty maintain workers'compensation insurance,as required by Se eflan 3700 of Me tabor code, <br /> for the performar+ce of the work far which this permit is issued. My workers'compensation insuranm <br /> carrier and poky numbers are. <br /> Carrier: I Policy Number <br /> I certify that in the performance of the work for which this perrnil is issued,f shall not employ any person in <br /> any manses so as to becomri Subject to the workers'comps rr&Abn laws of California,and agree drat if i ; <br /> sNWW becomes subjisct to the workers'compensation provisions of Serbon 3700 0l the tabor Code,I shall <br /> forihwlth Comply with those:provisions. <br /> i <br /> Dab: Signature- <br /> Prkftd Name- <br /> WARIVING!FAILURE TO SECUR!WORKERS'CCWVNMT)ON COVERAGE W UNLAWFUL,AND SHALL S B JEcr <br /> AN EMPLOYER TO CRRAINAL PENALTIES AND GIYIt_RNES tlP TO ONE HUNMD T"WS1A D DOLLARS <br /> 11 i,IN ADDITION TO THE COST OF COMPMSATJON,INTEREST,ATTORME"FEES,AND DAtitAM AS <br /> YI D FOR 11K SECTIO!3706 OF THE LABOR CCOE_ <br /> ^� I, (C-►7$tensed autherized mepmswda%m),be" <br /> aueh Zo , m <br /> to sign Wig&an Joaquin County Well P*mit Application an my behaff. I understand sibs audwrrration is valid far { <br /> F <br /> one 1 ear and IS liffl%W 10 Nps waric PhM dated an Me front egs arotis a ication. <br /> ,2 <br /> i <br /> TOTAL P.02 <br />