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Feb 08 02 09:46a <br />IV <br />Spectrum Exp. <br />209-465-8773 <br />San Joaquin County? nvnm ntal H alth5ervices, Unit 1V Well Permit Application Sle ent <br />JOB ADDRESS:¢ S'ow� �e.tifei St PERMIT SR <br />-1 Vic,h,�� <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />p.2 <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 #: <br />Date: oZ <br />Signature: <br />C57# 512268 Expiration Date: 04/30/2003 <br />Printed name: Brend <br />Contractor: Spectrum Exploration, Inc. <br />Title: Operations Manager <br />rawford <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />1 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 />X)L 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 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 prow ions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: a f Seo Signature: <br />Ur <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.x, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PR . VIDED. FOR iN SECTION 3706 OF THE LABOR CODE. <br />tit <br />I'`Brenda Crawford of Spectrum Explor .(signature ofC-57 licensed authorized representative), <br />. ,. <br />hereby authorize (print name) <br />to,o1gn,this San Joaquin"obnty Well Permit Application on my behalf. I understand this authorization is valid for <br />one t,x year and Is limited to the work plan dated on the front page of this application. <br />5-17-2000 1 Ml <br />