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08/20/2007 11:23 2094658773 SPECTRUM EXPLORATION PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT 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#: 5.12268 Expiration Date:_ 4-3p-09 <br /> Date: Contractor: Spectrum Exploration, Inc. <br /> Signature: /: ` Title: Location Manager <br /> Printed name: Brenda Crawford <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 Cade, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> National Union Fire - WC 159 3164 <br /> Carrier: Trnatirnnrp—j_ompan3r PvAcy 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 California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. 1�fpJt 66 � J <br /> Expiration Date: 4-1 -08 Signature: 1 ^J <br /> Printed Name: Brenda Crawford <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),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 /> AUTHORIZATIONFOROTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �Ixs 1, L_D Y L—NF1I ,, (signature ofC-67 licensed Iauthorized <br /> representative), <br /> hereby authorize(print name) ( M M.. I� iL L,god 0 P 1 t f l' hn�r�l <br /> to sign this San Joaquin County Well Permit Application ou 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 /> 9-29-021 MI <br /> run <br />