Laserfiche WebLink
08/101/2004 09: 21 2094658773 SPECTRUM EXPLORATION PAGE , 0,1 <br /> San Joaquin County Environmental Health De artment Unit IV Well Permit Application Supplement <br /> / 7519�p 5. ECSo <br /> JOB ADDRESS: 7f/) PERMIT SR#: 512 X91 R ? <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 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 tF: 512268 Expiration Date:_4130105_ <br /> Date o or: Spectrum Exploration,Inc-_— <br /> Signature: 71t1e: _Opyarations Manager <br /> Printed name: Brenda Crawford_ <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONS) <br /> _I have and will maintain a certificate of consent to self ensure for workers'compensation,as provided for <br /> l by Section 3700 of the labor Code, for the performance 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 /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> l carrier and policy numbers are: <br /> Carrier• National Union Fire Insurance Co. Policy Number: 6436303 <br /> I certify that in the performance of tre work for which this permit is issued, I shall rot 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' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> g-r/L 64__J Signature: <br /> Printed Name: Brenda Crawford <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 /> ($100.000.), IN ADD'iTION TO THE COST OF COMPENSATION. INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> \' H0R ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, BrerJ 'Faw/ord,of Spectrum Exploration.Inc.—(signature iofC 57 licensedd�nauthorized repiesen'rUve),( 1 <br /> hereby authorize(print � 9P 0 ll/Adcp- C�.OTVI —T 1i r <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> Lone(1)year and is limited to the work plan dated on the front page of this application. <br /> 8 29-021 MI — <br /> oCrCnlrn rtKAr nein ir, n n.h, Y�V <br />