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.Fiug;, D9`4 Ob: 30a ectrum Exp. -465-8773 p. 2 <br /> San Joaquin Cou nviron &ntal Health Services, Unit N Well Permit Application Sup le ent <br /> JOB ADDRESS:Q) �`>�2 •OSS' L3 PERMIT SR#: 0 0 <br /> I <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> j I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 d the Business and Professions Code and my license Is In full force and effect. <br /> 1 <br /> Ucense#: C57# 512268 Expiration Date: 0 4130/2003 <br /> Dater Q d ! Contractor: Spectrum Exploration, Inc. <br /> Signature Title: Operations Manager <br /> Printed name: Brenda rawf ord <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: 3B(;03575800 <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 became subject to the workers'compensation laws of California,and agree that if I <br /> stmid become subject to the workers'compensation gions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 8� �d10�—" Signature: <br /> Printed Name: Brenda ford <br /> E <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 /> t ire, I -'Brenda Crawford of Spectrum Explor.(signatureofC-67licensed authorized representative), <br /> i "�i•3`;' <br /> hereby authorize(print name - <br /> to.alyn,this San Joaquin County Well Penult Application on my behalf. I understand this authorization Is valid for <br /> ondyear-end Is limited to the work plan dated on the front page of this application. <br /> Ft-17-2000/Mi <br /> In4 <br />