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Jul 01 02 08: 36a Spectrum Exp. 209-465-8773 p. 2 <br /> 'w <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /7wlPERMIT SR#: <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 /> is 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#; C57N 512268 Expiration Date: 04/30/2003 <br /> Dale: d� Contractor: Spectrum Exploration, Inc. <br /> i <br /> Signature: Title: Operations Manager <br /> `i Brenda rawford <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _1 have and will maintain a certificate of consent to self-insure for workers compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br /> XX_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 /> i <br /> Carrier. American Motorist Policy Number: 313GO3575800 <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 prov ions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> jDate: Signature: <br /> i Printed Name: Brenda C wford <br /> l <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 /> ;I (: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. <br /> f kJBYenda Crawford of Spectrum Explor -(signature ofC-57 licensed authorized represent live), <br /> } <br /> Manby authorize(print name) <br /> sign <br /> � N alpn thle San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one( yspr and Is limited to the work plan dated on the front page of this application. <br /> � _ F-17.1000/MI --- <br />