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10/17/2007 12:18 2094E53773 SPECTRUM EKPLCRATICN PACE 01 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:__ »_� PERMIT SR#: Z3Z f <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(ccmmendng with Section 7000)Of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> LicensaM 51226 1 Expiration Date:- 4-30-09 <br /> Date: 7 Contractor. Spectrum Exploration. Inc. <br /> Signature._, �G / Title: Location Mana e� r,� <br /> printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby alrm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a Certificate of consent to self-Insure for workers'compensation, as provided for <br /> i <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> X I have and wilE maintain vomiters'compensation insurance,as required by Section 3700 of the tabor Code, <br /> I"" <br /> the performance of the work for which this permit is issued. MY workers'Compensaimon insurance <br /> carrier andpdiCy numbers are: <br /> National Union Fire - wC 159 3164 <br /> Caller. -rx--- -- ^ m{>-.--�----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 Califomia,and agree that 01 <br /> should become subject to the workers'compensation provisions of Section 3700 of the labor Code.I shall <br /> forthwith comply writh those provisions. <br /> Sf nature: <br /> Expiration Date: A-1-0 8 <br /> 9 <br /> Printed Name: Brenda Crawford <br /> PENSATION COVERAGE IS UNLAWFUL,AND SHALL <br /> AWARNING:FAILURE TO SECURE N EMPLOYER 7O CRIW14AL PENALTIES AND NP1L NES UP TO ONE HUNDRED THOUSAND DOLLARSUBJECT <br /> IN ADN ITION T N 14E OAF THE COMP NSATCODEIONINTEREST,ATTORNEPS FEES,AND DAMAGES AS <br /> PROVIDED FOR <br /> AUTHORIZATION <br /> FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> --(signature ofCb7 licensed authorhOd`representative). <br /> hereby authorize(print ndme) <br /> in sign this.San Joaquin County Wall permit Application On my behatf. 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 /> 8-29-02; <br /> pplication.8-29-027 MI <br /> r•4n 79-02-MI <br />