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03/18/2005 12: 06 2094658773 SPECTRUM EXPLORAT' PAGE 02 <br /> f <br /> U jL _ - <br /> San Joaquin County Environimental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ��� CJ!t r� PERMIT SR#:�` l _ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hemby affirm that I am licensed under the provisions rrf 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: Co tractor. Spectrum Exploration, Inc. <br /> Signature: Title: 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 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 1 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: 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 became 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 /> Expiration Date: 04101105_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 FINE$UA TO ONE HUNDRED THOUSAND DOLLARS <br /> (b1(I0,0GG.),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTORN'EY'S PEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> -AUTHORIZATION FOR OTHER THAN CZ7 SIGNING PERMIT APPLICATION <br /> I, ]'Jranda rd, of spectrum Exploration, Inc._(signature ofC-S7 licensed authorized mprasenratlw), <br /> hereby authorize(print name) <br /> to Cign thla San Joaquin County Well Permit PRppiiaadon on my behalf. I understand thin outharization is valid for <br /> once(1)year and is limited to the work plan dated on the front page of this application. <br /> ` <br /> LO-29-02 1 MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />