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0610212003 13:40 2094650773 SPECTRUM EWLORATION PAGE 03 <br /> E ' <br /> 1 <br /> San Jonquin County Environmental Health Depart Ment Unit IV Weill Virmit Appiiaatian Supplement <br /> ' JOB ADOREgS;,M]r��b8 8. AeYALM �'�1 �T` 3R#; <br /> ` <br /> LICENSED CONTRACTORS DECLARATION � ) <br /> ' s I heretry affirm that I am iieensed under the provisions of Chapter 9(cwrnrrendrq with Section 7000)of Division <br /> ! 3 of the Business and Professions Code and my license is to full force and offed. <br /> License 0; _ ___ 542268_ _ .... EVIndbn Date:_rI Sew <br /> Date: 3 CcxrtreCGnr.Spectrum b:xptoration,ins <br /> Signature: <br /> Tltte:Operations Manager________,.,. <br /> Printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I herebV affirm under penalty d perjury we of the tdlaNing daclaretions: (CHECK ONE) <br /> I have and mill maintain a certficaW d consent to seH4insure forwork$W oompensation,as provided fa' <br /> by Section 3700 of 0-aLabor Code,for the performance of the work for which this permit is issued. <br /> X I haveaid will maintain workers'Compensation insurance,as required by Sedion 3700 of the Labor Code, <br /> .. ..for the performance of the work for which this permit is Issued. My workers'compCnsarticn insurance <br /> and d policy numbers gra: <br /> Carrier; L.umberman's Mutual Potioy Number:3BA164321D1 . <br /> I certify that in the pwformarrcer of the work for which this permit Is issued.I shall not employ any parson in <br /> l any manner so as to became mkod to the Workers'compensation Iaws of Cdifotrua,and agree that If I <br /> i dwuld become subject to the worken'emperwaSon provisions of Section 3700 of the Labor Code,I shall <br /> l fcrWWO comply with those provisions. <br /> Date:_ to signature* <br /> signature• <br /> Printed Nlun►e: Brands Crawford <br /> i <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINDS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> Psi�OVlt) IIaCRDN STION To THE CoSyOF 6C rl M 37t78Tr tE LABOR CODE1'ION,INTEREST,ATIORt�EY'S#EF.ffi,AND LlANlAti69 AS <br /> OTION FOR QW.,, THAN C-wSIGNINGPERMIT APPLICATIONICATION <br /> Re <br /> _B Spectrum <br /> Explomllon,Ina (signaturo*M-ST pawned suMorlaarb rspmuntetivaL <br /> ti � <br /> hereby authorize(print named), . <br /> h. <br /> to sign this San Joaquin Cvtrnty Well Permit/Application an my behalf. I understand this authortxaUon is velid for <br /> one(e)year and Is Ilmitsd to Wa work plan dated on the front page of this appbicadon. <br /> 6.29421 MI <br />