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01/20/2004 12:53 209465 <br /> SPECTRUM EXPLOR ON PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV 1Nell PermR Application SupplemeQnt <br /> .IOs ADDRESS-111 <br /> nDRESS: 34 7 <br /> PERMIT SR#: � � 'v <br /> S-f��K I C�- <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# 5'12268 Expiration Date:_4/30105 <br /> Date: Contractor Spectrum Exploration.Inc. <br /> :7i�� Title:_Operations Manager-- <br /> Signature., <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 self-insum for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this perrnit is issued. <br /> X_I have and will maintain workers'compensation insurance, as required by <br /> on3700f he Labor <br /> Code, <br /> rs' <br /> for the performance of the work for which this permit is issued. Mycompensation <br /> carrier and policy numbers are: <br /> Carver:,National Union f=ire Insurance Co. _ Policy Number: #7165639 <br /> person <br /> I certify that in the performance of the work for which this permitis i sue , I C all not ae and agree that f I�n <br /> any manner so as to become subject to the workers'comps <br /> should become subject to the workers'compensation provisions f 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 15 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 /> ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1,_B da Crawford,of Spectrum Exploration,Inc.,^,,,(signatum ofC-57 licenced authorized representative), <br /> 0 Ithereby authorize(print name) +itdfkK. G �lrr <br /> to sign this San 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 /> 8-29-021 MI <br />