Laserfiche WebLink
06/O2/2i303 23:40 2094658773 SPECTRUM EWLORATION PACE 03 <br /> a <br /> San Jo"uin County Em+ironmental health Department Unit N Well Permit Appkmftn Supplement <br /> JOB ADDRESS- 8. <br /> . <br /> LICENSED CONTRACTORS DECLARATION (L) <br /> 1 hereby affirm that I aM licensed under the provisions Of Chapter 9(axnrrlertcing with Se on 700D)Of Drvist)n <br /> 1 3 of the Business end prafessiorvs Code end my license is in full force end eff0d. <br /> l..icensa 0:—592268 f;;V]nrtlon Data..,_„_"W <br /> Date: 12 Lh S i Corlttactor.Spectrum>x*mtion,Inc, <br /> signature: <br /> Title:.,_0parRUDAS IYlslnsgeir�_ <br /> YEE <br /> Printed nerve: Sronda Crawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedury one of they foifawing deCleratians: (CHECK ONE) <br /> I have and vrill maintain a cetiificatod consent to saWnsum forvmrk$W OOMPensetion,as Provided fpr' <br /> by Sectlon 3700 of lige Labor Code,for the perisorrnuCe 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 /> — <br /> for the palonnance of the work for which this pemsit is Issued. My vmrkere coMpeneaticn insurance <br /> carrier and policy numbers are: <br /> Carrier; Lumberman's Mutual Pouchy Number:35AIS02107___ <br /> I certify that in the pwfor mance of the work for vAlch this permit is iasi,lW.I shall not employ arty Person in <br /> any manner so as to become sub od to the workers'compensation laws of CeliforNa,and agree that I I <br /> i dwuld boomw subject to the workers'Compermation pn7visions of Section 3700 of the Labor Cade,I stall <br /> I fodtwtNh comply with those provisions. <br /> Date; (0 1 a-to Signature: <br /> ___JSmndo craawwrd I <br /> I a <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COI/!* GE 13 UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($400,000.), <br /> INADIDiT C TO HE COSTHE LABOR COMPECODENSATION, <br /> INTEREST,ATYORNEY'S FEES,AND DAMAGES AS <br /> PROVORIZATION FOR 0 THAN C-57 SIGNING PERMIT APPLICATION <br /> I,_B wfa►d.of Spectrum Exalorstton,Inc jaipnitun aiPC•57 l[cerhiid etttlharlxed representative), � <br /> hereby authorize(print normo) i3 _ t1 <br /> to sign this San Joaquin t.vtmty Well Permit Application an my behalf. I undsmand this authorization is valid far <br /> i <br /> ane(1)year end Is HmM d to the work plan dated on the front Pigs of this aPPkatinn. <br /> S-49421 MI <br /> I ` <br /> I <br />