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ti <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applicatiop Supplement <br /> JOB ADDRESS: lfl�C.4G 19 �✓- IA PERMIT SR#: Or� <br /> b � <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* 512268 Expiration ate: 4-30-07 <br /> Date: Contractor: Spectrum Exploration#ExplorationInc. <br /> Signature: Title: Location 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 self-ins re 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 /> National. Union Fire Policy umber: 717 1494 <br /> � <br /> Carrier: y i <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 I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> E forthwith comply with those provisions. <br /> i <br /> Expiration Date. 4-01 —07 Signature: <br /> Printed Name: Brenda Crawford i <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION OVERAGE l5 UNLAWFUL,AND SHALL SUBJECT i <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS is <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. i <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (si nature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) ` <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 /> FHD 29-02-001 <br /> 6122104 <br />