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lsw <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:7500 W. 11th. Street, Tracy CA 95304 PERMIT SR#: <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#- C57 512268 Expiration Date:_ 1304/zooa— <br /> Date:–3J <br /> Con ractor: S ectrum Exploration, Inc, <br /> Signature: Title: <br /> Printed name: twt <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for whit !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 policynumbersare: <br /> Carrier. i4►1 ive Policy Number: to 4s3 <br /> 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' co a tion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: t3Zy .,_ Signature: <br /> Printed Name: lr✓� (/L (��.� <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($ 00.). IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVI D FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby thorize (pri n e Dai Watkins(Geotechnical Engineer-The San Joaquin Company Inc.) <br /> to sign this San Jo in County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one (1)year and is limited to the work plan dated an the front page of this application. <br /> 1-25-02 1 MI <br />