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11/04'/2005 13:59 20946587 SPEC RUM EXPLORJ;P� PAGE 02 <br /> D i <br /> i <br /> 9 I <br /> is <br /> San Joaquin County Environmental Health p9partmant Unit IV Well Permit Appllcatt u plemon <br /> If <br /> S.• Da 1 15 00014 CRL4 FVM1 A ST, PERMIT SRF:STVC114-Tv%a <br /> / <br /> JOB ADDRES <br /> i <br /> LICENSED� CONTRACTORS DECLARATION (LCD) r <br /> 1 he reby affirm that I am licensed under the provisions of Chapter 0 (commencing with Section 7000)of Division <br /> ot'the Business and Professions Code and my license is in full force and effect. <br /> i <br /> Licanse#: 5 Exoration D 04-30-07 <br /> j <br /> i <br /> Data: 11' -05 Contract . s ectrum Ex ora nc <br /> LL I'Stgnature: - - ]: <br /> -Manager.! - - - <br /> ''_ Regona - .. _ <br /> Printedname'. <br /> j <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> `t horeby affirm under penalty of perjury one of the following declar 'ons: (CHECK ONE) <br /> I <br /> f have and will maintain a certificate of consent to sag-insure for workers'compensation, as provided for <br /> � by Section 3700 of the tabor Code, far the performance of the work for Which this permit is issued. <br /> _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. National union Fire Policy Nu ber: 1177860 <br /> , <br /> I certify that In the performanos of thework fo pe it is issued, I shall not employ any person in <br /> any manner so as to become subject to th rkers'corn n atlon laws of Califomia, and agree that if I <br /> should become subject to the workers'co rection provi ons of Secti n 3700 of the Labor Code, I shall <br /> forthwith comply With those provisions. <br /> I <br /> Ex airatlon pate: n 4-3 0_n 7 Signature: <br /> Printed Name;_M m 7c 13f;6jilt-r <br /> i <br /> ^WAANING:.FAILU.R�TQ SE tJRE YYt RKirR9"CCMPBtM[BATION.GO.. .__ E IS.UNI,AWFUL,Ah�D-StiAt.I..St�I3.tt:C7. . �. <br /> AN EMPI.OYER TO CRIMINAL PENALTIES AND CML FINES BJP TO )NE HUMMI)THOUSANDRS <br /> ($100IiDED DR N SECTION T 8 OF T OF COMPMOR CGDE ON,INTE 1;E <br /> EST,ATTORNEY'S F9,AND DAMAGES,AS <br /> PRO <br /> AUTHORIZATION FOR OTHER THAN C-BT,SIGNING PERMIT APPLICATION <br /> I, re afC47 licensed authorized representative), <br /> hereby authorize(printnarr ) NS 11{!G %/t4kf7' lrLliJbi i N� <br /> to:sign this San Joaquin County Welt Permit Application an my behalf. I understand this authorization is valid for <br /> on'P(h)year and is limited to the work plan dated on the front Pape of this application. <br /> L114-12-02 I MI <br /> E' <br /> 6/22!04 <br /> 14 <br /> I� ' <br />