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w Seg 26 02 09: 22a Spectrum Exp. 209-465-8773 p. 2 <br /> i� San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> a <br /> JOB ADDRESS: a�ePERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 /> License# G1 C57# 512268 Expiration Date: 04/30/2003 <br /> Date: A Contractor: Spectrum Exploration, Inc. <br /> Signature: Title: Operations Manager <br /> Printed name: BrendalLawford <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 certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,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 <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 prov ions of Section 3700 of the Labor Code, I shall <br /> forthvyith comply with those provisions. <br /> i <br /> Date:_ 1 f d�— Signature: <br /> Printed Name: Brenda C wford <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 /> +� ($100,000.) IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> i <br /> PRVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> � '. <br /> r h�`Brenda Crawford of Spectrum Explor.(signature ofC-57 licensed authorized representative), <br /> ,. �h�l Doss <br /> t hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> ono(1)year and Is limited to the work plan dated on the front page of this application. <br /> 6.17.20001 MI <br />