Laserfiche WebLink
SENT BY: SPECTRUM; <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: kg-fl Ea-f h-e STOLg+A—PERMIT SR#: <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 />3 of the Business and Professions Code and my license is in full force and effect. <br />License it: C1 Ii 1 2 2 6 `r.-.1 Expiration Date: 04/30/2003 <br /> <br />Date: Contractor: Spectrum Exploration Inc _ <br />5- 4- 1 4:55PM; 4658773 => 2094683433; #2/2 <br />Title: Operations Manager Signature: <br />Orowtord <br />WORKERS COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one Of the following 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 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />xx 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: American Motor it <br />Policy Number: 313C 0 3 5 7 580 0 <br />I certify that in the performance ol 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 California, and agree that if I <br />should become subject to the workers' compensation prov ions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: 5-- q -o Signature: <br />Printed Name: Brenda Ct.éwf ard <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 ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />1, Hrcul(la (:,::17 w ()nil (-) SPet,' r "I" ExP c)r •(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) (411Se-c4 OC. Aed(Lod <br />to sign dila Sari Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />6-17-2000/ MI . . <br />5 9\00 2-G, \s4- <br />Printed name: