Laserfiche WebLink
03/31/2003w 13:29 2094658773 <br />SPECTRUM EXPLORATION <br />I f05, 2 7�) ()S ^ 5 „ <br />( [ -- , - l/ --v <br />'n County Environmental Health Depa <br />PAGE 02 <br />nit IV Well Permit Application Supplement <br />San oaqur <br />JOB ADDRESS: NOS -k nt� FA 1- � t' 30" 2 P — PERMIT SR#: 3 O <br />FI-Zf-�� <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*: 512268 Expiration Date: 4130/03 <br />Date: <br />Signature: <br />Printed name: Brenda Crawfo <br />_Spectrum Exploration, Inc <br />Title: _Operations Manager <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 />Carrier: Lumberman's Mutual Policy Number. 3BA16432101_ <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 provisi ns of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Date: - <br />Printed Name: Brenda Crawfo <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SURJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />ISECTION ADDITION TO <br />E COST OF T LABOR OFCOMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED OR <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, _Brenda Crawford, of Spectrum Exploration, Inc.^(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this San Joaquin County Well Permit Application on my behalf- 1 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 />8-29-021 MI <br />