Laserfiche WebLink
12/06/2004 10: 02 2094658773 SPECTRUM EXPLORATION PAGE 01 <br /> Sa,n Joaquin County Environmental Health Department Unit W Wall Permit Application/Supplement <br /> JOE ADDRESS: 1Ti PERMIT S-#: <br /> 1i 52-3'7 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I herby affirm that I 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#: 512268 Expiration Date: 4130105 <br /> Date: 0 Cor ctor:_Spectrum Exploration, Inc. <br /> Signature: Title:,_Operations Manager <br /> t— <br /> Prinl;ed 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 /> 1. arrler: _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, 1 shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: Brenda Crawford <br /> WARNING: FAILUR.F 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 /> PS ' ,IN DIN SECTION TO HE COST OF OF COMP NS TION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> R(1�DEDOR <br /> 17ra-� rdofORIZATIOdonI, ectrum ExploraInc._(siN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> inature ofC-57 licensed authorized representative), <br /> I1Sp9 l� <br /> hereby authorize(print name)_� l'lUiy•vt h I� I` ',1 <br /> to::ign this San Joaquin County Well Permit Application on my behalf. I understand this authorization;9 valid for <br /> one(1)year and Is limited to the work plan dcted on the front page of this application. <br /> L_8-29-021 6A1 <br />