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0C,/09/2006 16: 40 2094658773_ SPECTRUM EXPLORATION. PAGE 02 <br /> 06/09/2006 14:58 FAX `� y 'RECTUM zj war <br /> AL3 <br /> I San Joa u+n L'oun.t ..,,_..,.,............,T......._,.........—w_ U ..............._..........._........._..._....._._._.......__..........---- <br /> Environmental Heal h Department Unit IV Well Permit Applicatio Suopiement <br /> JOi3 ADDRESS: <br /> _... /...._. _...,___._ PERMIT SRS:_. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> r <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Liconso <br /> ^_� _ Expiration Date <br /> Date; — — -�_ - Contractor: <br /> j Signature' - Title, <br /> Painted name: -_a�c <br /> WORKERS' COMPENSATION DECLARATION <br /> I h'sreby affirm under penalty of perjury drip of the following declarations: (CHFCK ONE) <br /> _I have and will maintain a certificate of consent to self insure for workers'compensation, as provided for <br /> I <br /> r the performance of the work for which this permit is Issued <br /> by Section 3700 of the Labor Code. to <br /> . <br /> 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 /> nakiaral Llnilm R� <br /> Carrier: policy Number: <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 provisions of Section 3700 of the Labor Code, I shalt <br /> J forthwith comply with those provisions. <br /> E�pirationDate: NnL--O_—signature, <br /> Printed Name: <br /> V'AnN!NC' f'AILUnl1 TO SECURE WORKERS' COPAPENSATION COVERAGE IS UNLAWFUL,AND SHAI.,!, SUe7AEt:T it <br /> AN [MPLOVPR TD CR!MINnL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (4100,000.1.IN ACDirlON TO THE COS f OF COMPENSAnUN,tN't[RE5T,AT'rURNEY'S FEES, AND DAMAGCS AS <br /> {i PROVIDED FOR IN SECTION 8700 Qi- TWE LAOOR CODE. <br /> AUTHOR17-ATION FOR OT ER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature cfG-57 IicN.ns(d Kuthorized representative;, <br /> � r <br /> i I•mrehy Lauth Oriz¢ (print merit e)T•�,, 15 <br /> to Sign this aan Joaquin Counly Well Purrnit Application on my behalf. I undorr•larld this autltOriZatipn is vMld for <br /> j <br /> W the work plan dated on the front page o1 thls application <br /> ono{1)yr.ar anR : I+mited . <br /> lMl ..– -- ......................_._..,... <br />