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03f18f2005 12:05 25946587-- <br /> SPECTRUM EXPLOP ~ON PAGE 02 <br /> �J �1 <br /> c. — vj � <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: D4�{l8`5� <br /> PERMIT SR#:�` r <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I heroby 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#: 512268 Expiration Date:_4130105 <br /> Date- Go tractor Spectrum Exploration,Inc. <br /> Signature= Tithe: Operations Manager <br /> Primed 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-insure 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 /> 1:,arder: _National Union Fire Insurance Co. Policy Number: 6436303 <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 l <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 /> Expiration Data. 04107105. _ 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 /> ($1110,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATT'ORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE_ <br /> THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1,_Brenda rd, of Spectrum Exploration, Inc`(signature arFC-57 licensed authorized n.pn3sertatYve), <br /> hereby authorize(print narne) LdUUI t <br /> to Mgn this San Joaquin County Well Per nit Application on my behalf. I understand this authorization ire valid for <br /> once(1)year and Is limited to the wink plan dated on the front page of this application_ <br /> 8-2M21 Ml <br /> E14D 29-02-001 <br /> 6122104 <br />