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20 4658773 , EpEcTRUM EXPLORATI� <br /> PAGE 01 <br /> 12118/2002 14: 31 <br /> Ilcation Supplement <br /> BnviraAmental Health Services, Unit 1V Well permit App 3zZ�� <br /> 3 San Joaquin County <br /> 187 PERMIT SR#. <br /> JOB ADDRESS. <br /> CENSER CpNTRAC CORS DECLARATION <br /> LI isions of Chapter 9(Commencing vrith Section 7004)of Division <br /> 1 hereby affirm that l am licensed under the per+ license is in full force and effect- <br /> 3 of the Business and ProfeSSIOMS Code and my Expiration Date :_�413flf03 — <br /> License#: _5122613 <br /> pate . fyb — ContraCtor: <br /> Spectrum Exploration,Inc. <br /> Title: PPeratlons Manager__----, <br /> signature <br /> Printed name:—Brenda Crawford <br /> WORKERS' COMPENSATION DECLARATION THAT AT APPLY) <br /> � <br /> I hereby affirm under penalty of perjury one of the following declaretrons: CHECK a provided for by <br /> have and will maintain a certificate of consent to self-insure for workers' compensation,tis s <br /> { performance of the work for vvhieh this permit is issued. <br /> Section 3700 of the Labor Code,for the pe Section 3700 of the Labor Code, <br /> X 1 have and will maintain workers' comp <br /> ensetion insurance,as re <br /> vA)rkers' compensation in$urance <br /> for the performance of the work for which this permit is issued. My <br /> carrier and policy numbers are: <br /> Carrier:American Motorist policy Numtser. 3BG03S75800 <br /> person in <br /> agree that if I <br /> rti that in the per#orrnance of the work fwor�k ire' cormpensation laws of Gal farni employ <br /> and�9� <br /> 1 ce fy <br /> any manner so as b t so the mirkers'compensation provisi sof Section 3700 of the Labor Code. I shall <br /> should become swim those provisions. <br /> forthWttj comply <br /> Date: /;Z `�P�d — Signature: <br /> ord <br /> Printed Name: __Brenda Cra er^ <br /> AND SHALL SUBJECT <br /> TIES AND CIVIL FINES UP TO ONE HUN ORNEY'S FES AND DAMAGES ALLARS S <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENgATiON COVERAGEE14 'T UNLAWf , <br /> AN EMPLOYER TO CRIMINAL PENALTIES <br /> INTEREST,A <br /> ($1011,00E�,[IN <br /> RDj�SECTLaN 3705 0l=THE O THE COST OF: CODE COMPENSATION, <br /> PROVID / <br /> I,__Brenda Crawford of gpeotn,m Exploration,inc.�.(Signature ofC•57 licensed authorized r$presentative), <br /> hereby authorize(pri <br /> nt name) . <br /> San Joaquin County 1AleLL permit Appiicatian on my behalf. I understand this authorization is valid or <br /> to sign this <br /> his aPP"cation, <br /> one ('I)year and is limited to the work Plan dated on the front Page of t <br /> 647.2000 1 MI <br />