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SENT BY: SPECTRUM; 5-18 1 12:55PM; 4858773 => <br /> ---.S._a..._....... .._ ..y Env......v......,._...a_.......t............ <br /> _......... ........A. ......p........a..t.......... <br /> naaqnin Counttrrnnaleat#h ServlcU1Welt 'ernitplicln Supplement <br /> upp sfent <br /> JOB ADDRESS: � � �fLi � PERMrr SR#• <br /> # LICENSED CONTRACTORS DECLARATION (LCD) } <br /> I heieby affirm that I am licenw,d under the provisions of Chapter 9(commencing with SeCtion 7000)of Division <br /> 3 of the Business Fara! Professions Code and my license is in fell force and effect. <br /> Liicensu it: C`5 711 5 1 2 2 5 li <br /> " Expiralicx� €late: 04/ 30/2003 <br /> Date.: Coolf ac:tov spt,!Ct.r,urri Exploration I.nr. . <br /> Si "tum- - <br /> �...:... qat <br /> Title: Operations Martaq!t;.. <br /> Printed name: E?r�� r.;awt:rird <br /> WORKERS COMPENSATION DECLARATION ��_____.._...,....,..__.. <br /> i <br /> 1 hereby affirm under penalty of peroiry cmN rg the €ollowinq 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 37CA)of the Labor Codo-, for the performance of the vmrk for which this permit is is%ue.d. <br /> x. 1 heave and *11 nnzs ntain workers'ccamponeation insurance, as required by Section 3700 of the Labur Code. <br /> for the Performance of the work for which this permit is issued. My workers'compensation lnsuranr_s i <br /> carrier and policy menbers,arra: <br /> Carrier Ani r:��i.c t3ri rJlcat �,r_i ,t. --- --- Puiicy Number: 38GO3575800 <br /> I certify that in the perfonnance 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 Califomia, and free that if I <br /> should become subject to the workers' compensation prcov ions of Section 3700 of the Labra Code, I shall <br /> fafttrMth comply with those provislons. <br /> Date: ig r 4 <br /> PrintedName: E31:'enda (.`tAwford <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND VOLLAIRS t <br /> ($100,000.), IN ADVITIONf TO THE COST OF COMPENSATION, INTEREST,ATTOIRNEY'S FEES,AND DAMAGES AS � <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> i <br /> I' <br /> 6,:e,icl a t"z;a W f'u r d o i S Ea x'viiiµ 1:x p Z-0,r .(afgna rsre 0!0-67 gCensRd#UthOrliecf rei}res Aritativel. <br /> heroby authoriZe{print name) e4 Id <br /> i <br /> to sign this San Joaquin County Wolf Permit Application on my behalf. I understand this authorlxation is valid for <br /> one (1)year and is limited to the work plan doted on the front page of this application. <br /> 547.200011411 <br /> ..................... . .. ..............._....._.._._.....__..................._......... .. ....... <br />