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03/22/2007 15:43 209465870 SPECTRUM EXPLORATION PAGE 02 <br /> AWN �b <br /> San Joaquin County Environmental Health Department Unit IV Well Permit7. '/CL) <br /> Supplement <br /> JOB ADDRESS: 1 (;OYe" SAL 21 t� PERMIT SR#::00 5b <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#: X12 2 6 8 Expiration Date: 4-3Q-07 <br /> Date: 3t <br /> a 0 Contractor: Spectrum Exploration Inc. _ <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-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'compensatlon 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 <br /> Carrier: T —.irnmpaDy Policy Number: 717 1494 <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 /> Expiration Date: 4-01 -07 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 CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> DHE COST OF OF COMP CODE.ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDEDFOR IN SECTION 3 <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> 1 �1;D f O U L---- (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) itrV U 5 x 5 E&J <br /> to sign this San Joaquin County Wall 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 /> 8-29021 MI <br /> rHD 29-02-001 <br /> rrsiO4 <br />