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Aug 26 02 10: 42a SOtrum Exp . 21465-0773 p. 2 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ct' 1 G? �f��rt� PERMIT SR#: <br /> j 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 o(the Business and Professions Code and my license is in full force and effect. <br /> License: C57# 512268 Expiration Date: 04/30/2003 <br /> Date: ,P( D';1— A Contractor: Spectrum Exploration Inc. <br /> Sig re: Title: Operations Manager <br /> Printed name: Brenda irawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm udder penally of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self4nsure 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 wofkcrs compensation Insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work(or which this permit is Issued. My workers' compensation insurance <br /> harrier and policy numbers are: <br /> r <br /> i <br /> Cartier. American Motorist Policy Number. 3BG035 15800 <br /> I <br /> —i CeR fy that In the performance of the work for which this permit is Issued, I shall not employ any person in <br /> any mww so as to become subject to the workers'compensation laws of California,and agree that If I <br /> should became subject to the workers'compensatio4prov ons ofSection 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Data: ,p/a A�- Signature:Printed Name: Brendaford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> •i AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (f100,000.�IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PRO-VIDEO FOR IN SECTION 37D6 OF THE LABOR CODE. <br /> • � ' i"'Brenda Crawford of Spectrum Explor.tsl nature of"T lice neo d authorfxed representative), <br /> y �u au�21 0��� Nf11 ,, <br /> ' <br /> hereby avUwdzs(print name) <br /> ' - to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> j ono(1)year and Is limited to the work plan dated on the front page of this application. <br /> r (i-174000 f MI <br />