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03/31/2003 13:29 20946567 <br /> SPECTRUM EXPLORFH PAGE 02 <br /> 05 <br /> Son Jomgdn County enviratm»rfal liaarldt caw <br /> aN N <br /> :V�ftm <br /> it AppNcvwn SUPpiamet► <br /> JOBADDRESS'ti,.�< •t as tur~e PERMIT SRO.—Q-0 3 33ob <br /> LICENSED CONTRACTORS DECLARATION (LM <br /> 1 hereby etilmn that I am licensed urxler the PlOriefons of Chapter,g(oorrrmancing*'ith mon 7000)of DMsion <br /> 3 of the Buchu"OW professions Code and my loanse k in ftlll tome and sited. <br /> Verse* 512269 Expirstim Dale:^fd30✓bS <br /> Data: <br /> ntredor Spectrum Exploration,Ina. <br /> simature: <br /> TR1a:—Opefadvms Meea*ar <br /> Printed name: Brenda C <br /> WORKERS' COMPENSATION DECLARATION <br /> I Aeby dorm tactor Penalty of penury one of the following dedsratlons: (CHECK ONE) <br /> Wkw for <br /> _by section 3700 d the Labor Code,for penfomw"of the wnrk for Wddh��Is Issued. <br /> I have and will maintain workers'corrVwmdion inmxsrO a,as mored by Sacdm 37M d the Labor Code. <br /> for the perfomlanee of the work for whkh this pan*is issued- My workOW compereation insurance <br /> carrier and poky numbers are: <br /> CarMr: Lrerrbernan'a Mutual Policy Number:3BA154S2101 <br /> I owft Balt In the performance of the work for vMhkh this permit Is Issued, I"not employ arty POW In <br /> any manner so ea to become subject to the workWS'corrlpansedon laws Of Calllbrnia,and agnea teat if I <br /> should become subject to the workers' ooffPmustlon Of Section 3700 of the Labor Cade, I shall <br /> fordaaith comply with arose MmIsions. <br /> Dass: signature: <br /> Pfinted Name:____Bronda Crewbrd <br /> WARNING:FALL.URE 7O SECURE WORKERS'CON ipenATION COVERAGE W UNLAWFUL,AND SHALL SUBJECT <br /> AN EMIPI.OYER TO CRININAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUBANs DOLLARS <br /> PROVIDED FOR AIN ION TO THE SECTON 3705 OAF THE COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> AUTHORIZATION FOR OTHER THAN 0457 SIGNING PERMIT APPLICATION <br /> I,Brenda Crawford,of Spectrum Exploration,km_(sWature ofCC47 licensed augwd=d npnlw*111 e), <br /> heraby authotim(prlr*nems)_,to sign this San Joaquin County WON Pam ft Application On my belts. 1 understand We aullm ImAKerr Is valid for <br /> one(1)year and is Ilmitad to the work Plan dated on the front page of tide application. <br /> 19.29422 1 MI <br />