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06/23/2006 y 11:2`11 209465#4 -,mJ7o" SPECTRUM EXPLO CN PAGE 02 <br /> San Joaquin County Environmental'H/ealth Department Unit IV Wen learrrmit Application Supplement <br /> 106 ADDRESS: niro �_-!A! , d OS PERMIT SR#: -7I I� <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 /> ,I of the Business and Professions Code mY license is in full force and effect. <br /> license p: 2 Expiration Date: y' 3U`6-7 <br /> DaterL2:!&- ntractor -rr,N :/�L <br /> T <br /> 1i gnature: :_G JC.4'T/p �,1p(y EF(Z <br /> Printed name: i0c L M LEIE��t�1@ E <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the (bowing declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <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 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:NA7taNAr_ Nleu " r � o P1Tl pA <br /> (j FJs rrp F Policy Number: JQ C 7 <br /> ceri-ry that in the performance of the work for which this permit is issued, 1 s not emplcy any person in <br /> any manner so as to become subject to the workers'compensation laws life ia, and agree Opal if I <br /> should become subject to the workers'compensation provisions of S ion 3700 the Labor Code, I shall <br /> forthMih comply with those provisions. <br /> Expiration Date: -ti-07 Signature: zh <br /> Printed Name: 9 V7Jbc�� 14 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLA FUL,AND SHALL SUBJECT <br /> nN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED OUSAND DOLLARS <br /> ;5100,000J,IN ADOMON TO THE COS MPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37Dfi 01 <br /> HE LA R CODE. <br /> AUTIJOR17JkTION O OTKER HAN C-57 IGNIN PERMIT APPLICATION <br /> gnature ofCS7 licensed authorized representative), <br /> hereby aupiorize(print ram®) r A I O D <br /> to sign this San Joaquin County Well Permit plication on rmf behalf. I understand this authorization Is valid for <br /> one(1)year and is Iimiled to the work plan dated on the front past of this application. <br /> 8,29-021 MI <br /> ly{In 29-02-00! <br />