Laserfiche WebLink
11/bb/Zbb4 lb: YJZ Z1774b3C I I Sr'r-k,1 Buri C-^rLuRw 'UN rHur ul <br /> S2,n Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> ob0 ' 12�- :4, PERMIT SR#: 007`o � <br /> J�"9v, ADDRESS:--T /f — <br /> S�� 3Cc�C1� inJ Cc..t✓tY� GA , <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hen:by affirm aand F of�essions Code andrmySi enseions fishn full forceapter 9 andeffect with Section 7000) of Division <br /> 3 of the Business <br /> License##: 512268 Expiration Date: _4!30/05 <br /> Date: I 0 Cor ctor:_Spectrum Exploration, Inc. <br /> Signature: Title:_Operations Manager <br /> Primed name: Brenda Crawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 /> 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 /> carrier and policy numbers are: <br /> Carrier: _National Union Fire Insurance Co. Policy Number: 6436303 _ <br /> 1 certify that in the performance 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 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 /> Dat i': la-��� 0�1 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 13OLLARS <br /> PROVIDED ADDITION TION HE COST <br /> OF T LABOR OFCOMPENSATION;INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> DED FORIN SI <br /> AraORIZATV'ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> II wford,of Spectrum Exploration,Inc._(signatum ofC-57 licensed authorized representative), <br /> hereby authorize(print name)_ U IYyI K�,l <br /> to t:ign this San Joaquin County Well Permit Application on my behalf. I understand this authorizatlon is valid for <br /> onv (1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br />