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J` <br /> San Joaquin Catrnty Environmental Health Services,Unit IV Wetl Permit Application Supplement <br /> c <br /> JOB ADDRESS: + L PERMIT SR#• -' <br /> S 1 3 S r f. ad.Q- � 12�' --I- <br /> LICENSED <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 fuii force and effect. <br /> License k C57# 51 2 2 6 l3 Expiration Date: 04/30/2003 <br /> Da1e: — I Contractor S ectrurn Exploration Inc. <br /> Signature' <br /> Title: operations manager <br /> Printed name; Brenda rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I herby 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 /> XJ_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: 313GO3575BOO <br /> 1 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 became subject to the workers'Compensation laws of California, and agree that if I <br /> should became subject to the workers' compensation prov Ions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. _R <br /> Date: •„ v��19` 1_I _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 /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, Brenda. Crawford of Spectrum Explor.(signature ofC-57 licensed authonxed representative), <br /> 4) " 6�rGC) lv( !� <br /> hereby authorize(print name) n <br /> to sign this San Joaquin County Well Permit Appiication on my behalf. 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 /> 5-17.2000!MI <br />