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1211812002 14:31 '2094558 r T �=ECTRUM EXPL_OP"TON HAr <br /> l <br /> ___ _ — rhe <br /> San Joaquin Cr.�a�my Err�rir_oararnental Health Services, Unit IV Well Permit Application Supplement <br /> ,gas a RE ;�r876;-, _ PERN T SR#: DD 3zzgd <br /> 5V",_AA1 04. _ <br /> LICENSED CONTRACTORS DECLARATION (LCCA) <br /> I haveby alTiirm that 1 ani Iicensed under the provisions of Chapter O(cvrnrnenring with Section 7000)of Division <br /> 33 of the SL?51a1eSS and Professigrfs Code and my license is in full forc:�and effect. <br /> Licer se : _ 72 63_ _..� ��_Expiratit�n Data :_ 4430103 <br /> Date- <br /> Contractor, ,` Spectrum Exploration, Inc.. <br /> Signature: _ Y_ w �._Title. —Operratione Manager <br /> 1 Printed name:_Brt�nda Crawford__ <br /> Y WORKERS' COMPENSATION DECLA1 krION <br /> I }hereby affirms under penalty(if perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I haife rand wife maintain a certificate of consent.to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Ccde,for the performance of the work for w1iioh this permit is issued. <br /> _x_ ' li re,anzt l;rflf main#girl vv:3rF;er,' cnmpenssti�7ri insurance, as re€tuirni h Section 37CIO of'the Labor Code, <br /> For the performance o`the vvod,.for kvnich this permit is issued. My workers'o rnpenWion insurance <br /> carrier anri poligf numbem are. { <br /> Gaefler: —American t01.otorist Polim� Plumber:_38GO367MOO <br /> t cer:ity tivat in the performance of the worX for which this permit is issued, I shall not employ any person in <br /> any rnannr:r so as to become subject to the workers' oonipensstion laws of Cslifornia, and agree that if I <br /> wlfo:rlti hcuorne subject to the vvclrker9'Corrrpensatic'n prrlvisir/i`is of Se>,iori 3700 of the Labor Code, I shall <br /> i fnrthv{riti* comply with those provisions. fJ I <br /> Date; 1.� ";�� "� Signature; <br /> Printed Nar'ne: —.-Brenda Cra old <br /> WARNING': FAILURE 70 SEOURE W0RK �RS' C0NIPF.N 3A110N COVERAGE IS UNLAWFUL, AND SHALL.SUBJECT <br /> AN EMPLOYER70 CItI.MiNAL PENALTIES AND CIVL PINES UP TO ONE Ht1NDgEd THOUSAND aQLLA:RS <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST,Ir,TTORNEY's FEES, AND DAMAGES As <br /> PROV DED r-asp IN SECTION 3706 of THE LABOR CODE. <br /> 1,—_Brenda Cravklord cif Spectrum Exploration, Ine.._„_(signatum ofC:•57 licensed authorized mpresentative), <br /> *�4rrehy authorlxc (print namal ��/ ' �. c✓7Get1e __ �__�_ ____ _ , <br /> u sign this San Joequin County Well Permit Application on my bohalf, I undargta3nd this authoritarian is valid for <br /> one tt i year and is limited to the work plan dated tin the front page of thla appli(Ifttierr. <br /> $-17-20001 Ml <br />