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San Joaquin County Environmental Health Department U IV Well Permit Application Su plement <br /> 3VNJOB ADDRESS: . lZA•`7 PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCE)) <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 Date _4/30105 <br /> Date: I P! Contract r._ pectrum Exploration, Inc. <br /> Signature: Title:_,Operations Manager <br /> Printed name: Brands 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 selfynsure 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 /> 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 /> Carrier National Union Fire Insurance Co. Policy Number: 6436303 <br /> 1 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 /> forthwith comply with those provisions. <br /> I <br /> Date: 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 /> (5700,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ZRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I,_Bron opetrum 6xpiomtlon,Inc._,(ssiig�rnatum ofC-57 licensed a)utthorized representative), <br /> hereby authorize(print name) Ni lh r cty i ay?l dL 11 1 o i K. A-s��a_k S <br /> to sign this Sen Joaquin county Well Permit Application on my behalf. 1 understand this authorization ie valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 6-2M2/MI <br />