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12/09�2C11_15 14: 05 2094657:� SPECTRUM EXFLFRATIOhI PA!�E X14 <br /> 0 <br /> -to <br /> Environmental Health Department.Unit IV Well Permit Application Supplement <br /> JOB.A ADDRESS: PEST <br /> SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in Rill force and effect. <br /> License#k:512268 Expiration Date: 4/30147 <br /> Date:&48,9B3/.2.q-PS� Con ctor: rum Exploration,inc. <br /> Signature: Title:Location Manager <br /> Printed name: handy Dockery <br /> WORKERS' COWENSATION DECLARATION <br /> I hereby affum under penalty of perjury one of the following declarations: <br /> (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided <br /> TOT <br /> by Section 3700 of the Labor Code,for 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 <br /> 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 Insurance Policy Number: WC 1177860(CA) <br /> i certify that in the performance of the work for which this permit is issued,I shall not employ any person <br /> in 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 /> Expiration D;ate- 6 <br /> Signature: <br /> Printed Name: Malady Dockery <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS tlNLAWFULi AND SHALL <br /> SU11JECT <br /> AN F,MPI_.OYER TO CRIMINAL PENAI.MS AND CIVIL FINES ITP TO ONE uuNDUr,D THOUSAND <br /> DOLLARS <br /> (SI00,000.),INADDITION TO THE COST OF COMPFNSATTON,iNTER ST,ATTORNEVIS FEES,AND <br /> DAMAGES AS <br /> PROVIDED FOR iN SECTTON 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT <br /> APPLIJC.. TION <br /> I, (siviiatiore of C-57 licensed enthori7.ed re,preAentative),hereby authorize: <br /> Fliraheth nt, ark Wottfa,CH2 . Inc.to sign this San Joaquin County Well Permit Application on my <br /> bobalf,I sI 0ntand this authorizad valid for one(1)year and is limited to the work plan dated on the front pitge <br /> of this applicwtion. <br /> 8-29-021 MI <br /> END 27-02-001 <br /> 607/04 <br />