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08/10/2006 08:31 2094658773 SPECTRUM EXPLOrRATION PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Wall Permit Application Supplement <br /> JOB ADDRESS: 930 Cka 0 PERMIT SR#: <br /> `Y1 r C.pr <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I with Section 7000) of Division <br /> licensed under the provisions of Chapter 9 (comment ng <br /> hereby affirm that t am lice p <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 51 7 S 8 Expiration Date: 4 30-0 7 — <br /> fDate: Contractor: Spectrum Ex oration Znc- <br /> Signature: Title: Location Mann er <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-insure for workers'compensation, as provided for <br /> Labor Code for the performance of the work for which this permit is issued, <br /> by Section 3700 of the La p <br /> X I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br /> permit mit is issued. M <br /> for the performance of the work for which this r y workers' compensation insurance <br /> carrier and policy numbers are: <br /> National Union Fire <br /> Carrier: Policy Number: 71 7 1 494 <br /> Tr,c„ranr-P CnIn�,�'��� — <br /> I certify that in the performance of the work for which this permit is issued, I shali 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 /> forthwith comply with those provisions. <br /> I:xplratlon Date: 4-01 -07 Signature: <br /> Printed Name: Brenda Crawford <br /> INARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 8100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> +'ROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, Lar, 4rcisignature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) 91jeP 1` &AAaT�'1 <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 /> L8-29-02 1 Ml <br /> D ID 29-02-001 <br /> U''-2l04RECEIVED TIME AUG. 10. 8: 12AM <br />