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Now 20 01 10: 28a Spectrum Exp. 209-465-8773 P- 2 <br /> r <br /> e ' <br /> 1 <br /> San Joaquin County Environmental Health Services,Unit N Well Permit Application Supplement <br /> OB ADDRESS: nd �'�'1IC1ari � S+PERMIT SR#: <br /> I <br /> LICENSED CONTRACTORS DECLARATION (0-0 <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Dtvision <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> _ ucetM*. <br /> C57# 512268 Expiration Date: 04/30/2003 <br /> Date: 71f I--�Orol ' Contractor: Spectrum Ex loration Inc. <br /> Signature: Title: O erations Mana er <br /> Printed named: at <br /> rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certficate of consent to self-insure for workeW compensation, as provided for by <br /> Section 3700 of the Labor Cade,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 /> Carrier; American Motorist Policy Number: 3BG03575800 <br /> I certify that in the performance of the Work for which this perrnit 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 'ons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: -aQ"Q Signature.• <br /> Printed Name: Brenda C wf ord <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 /> FOR <br /> $100,PROVIDED ADDITION <br /> 37 B OF THE LABOR CODE. <br /> ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> I� Brenda Crawford of Spectrum Explor.(signature ofC-57 licensed authorized representative), <br /> It <br /> hereby authorize(print name) ( t 1 r irn <br /> j <br /> to sign this San Joaquin County Well 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 /> 5-17.20001 Ml <br />