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'L QUO lUe Gf LV J�VJVifJ ✓1-Llll\VI'1 LlII.LIJI\>wl 1VI1 ."'f\/L VG',. - ' <br /> � 1 <br /> San Joaquin County Environmental Health Department Unit FV Well Permit Application Supplement <br /> JOB ADDRESS: ` e9a 1 lzo 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 Cade and my license is in Full force and effect. <br /> License#: 612268 Expiration Date: 4130105 <br /> Date: 1 i 0 3I AContractor _Spectrum Exploration,Inc, <br /> Signature: dllTine:_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 worts for which this permit is issued. <br /> X I have and will maintain workers'compensation insuranoe,as required by Sedion 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: #7166639 <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 <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: () 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 /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED ICOR IN SECTION 3706 OF THE LABOR CODE. <br /> A ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I,�Bda .of Spectrum Exploration,Inc,_(signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) 1`'CL"L <br /> f <br /> to sign this San Joaquin County VI Wl 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 /> 8-29-021 MI <br />