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11/07/2063 16:27 2694658773 SPECTRUM EXPLORATION PAGE 02 <br /> t <br /> San Joaquin County Environmental Health Department Unit IY Well Permit Application Supplement <br /> JOB ADDRESS: 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 512268 Expiration Date: 4130105 <br /> Date: A A Contractor: Spectrum Exploration,Inc. <br /> Signature: Title:—Operations Manager <br /> Printed 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 self4nsure 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: #7985639 <br /> I 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 California, 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 /> Date: i) 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 CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($900,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I,B a rd,of Spectrum Exploration,Inc._(signature ofC-57 licensed authorized representative), <br /> hereby authorize(Print name) <br /> to sign this San Joaquin County Wert Permit Application on my behalf. 1 understand this authorizatlon Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> �� ©� <br />