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rHkaL n l <br /> FJO <br /> County EmrironrrtcAWIHealthDepartment Unit IV Well Penntk Appaloatk M Supplement ADDRESS: <br /> PERMIT SRS: <br /> LICENSED CONTRACTORS DF-CLARATION L <br /> I herrpby affirm that I am licensed under the provisions of Chapter 9(commencing vAth Section 7000)of Dlymian <br /> 3 of the Business and Professions Code and my lioense is in fun force and effect. <br /> �iG@fi8�2*: 512268 Expiration Date, 4�3t)lt] <br /> Date: !in 8 contractor spectrum Exploration, <br /> Sipgnature; Tale: operations ManWt__ ,,,_.— <br /> PrhlbLtd name: Erenda Crawfofd <br /> WORKERV CoMPCNSATION DECLARATION <br /> I hereby affirm under penalty of pedury one of the following declarations: (CHECK ONE) <br /> I.have and vAl maintain a rertifccate of consent to self-InGUM for workers'eornpensation,as provided for <br /> by Section 3700 of ftLaW Code,for the perfbi-mance of the work for whlch this permit is Issued, <br /> I have an wilI maintain W0rker9'compensation insuran e,as required by Section 3700 of the Labor Code, <br /> I&the performance Of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy number are: <br /> Carrier; .N*Wnal Union Fre Insurance Co._, .�Policy Httfnber. <br /> l certify that in the pedQjTna=of the work for which this permit is issued,I shall next emPloY any Persorl in <br /> any manner so as to become subject to the workors'campel�sa�'l'a SectiOf on 3?00 rn the Maar odea t shall <br /> should bec offm subject to the workerV CoMpensation provisions <br /> forthwith Comply with those MvisiOns- <br /> Dato:--ib , Signature: <br /> printed Name: 8randa Cray turd <br /> WARNING:FAILURE TO sEcURE YMKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJF-CT <br /> AN EMPLOYER TO CRIMINAL_RENALTIES ANI)Cl\gt,FINES UP To OtIE HUNDItplrl THOUSAM13 DOLLARS <br /> ($100,000.),IN ADomON To THE COST QF COMpBNSATION,INTEREST,ATTORNEY'S FE15S,AND DAMAMS AS <br /> PFOMDE13 FOR 1N SECmN 3706 OF THE LABOR CODE. <br /> U ORIZATION FOR DTN�✓l THAN C-57 SIGNING PERMIT �IPPI...ICATION <br /> I, far did,of Spm"m Explora lon,Inc._,(s;9n1ktutb W4 Iteerts¢Lt aetttarrized I� ve), <br /> wwaby authorize(pN l__ <br /> to sign ails Sart Joaquin CouM Well permit Application on my behalf_ 1 nndarsiand iftis auth4rizgtlan is varld far <br /> rnm(i)year and is limftd to the work pin dcttad on the fmit page of this application. <br /> La'74-v7 f Mi <br /> d LIOI e9S LOL QWIJ-ISI 3MUW IIIH WZHO dzI :EO SO 60 qaj <br />