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10/10/2007 12:10 2094658773 SPECTRUM EXPLORATTnN PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applicatl n Supplement <br /> JOB ADDRESS: O N. PERMIT SR#: <br /> 72"�t� <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commenting with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: S12268 Expiration Date'_ 4-30--09 <br /> Date: Contractor Spectrum Exploration Inc. <br /> Signature: Title: Location Manager <br /> Printed name: Brenda Crawf ord --- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm 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 /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> X 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 insurarn e <br /> carrier and policy numbers are: <br /> National Union 'Fire WC 159 3164 <br /> Carrier: Tngui-ante CompanW _Policy Number: <br /> 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,t shall <br /> forthwith comply with those provisions. <br /> 7aaw-L�� <br /> Expiration Date: 4-1-0£3,_Signature: <br /> Printed Name: Brenda Crawford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1S UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (sioo,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A$ <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. p U b �-(signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) A LEXI��-��� <br /> to sign this San Joaquin County Well Permit Application on my behatf. I understand this authorization is valid for <br /> one(9)year and Is limited to the work pian dated on the front page of this application. <br /> 0-29-021 Ml <br /> non�a.nz.aoi <br />