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03/31/2003 13:29 2094658773 SPECTRUM EXPLORATION PAGE 01 <br />`jL4,;- <br />artment Unit 1V Well Permit Application Supplement <br />San Joaquin County Environmental Health Dep O 3 <br />B ADADRES <br />S: h PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (-L-CD) <br />I hereby affirm that I am licensed under the provisions o is in fine force �d den with Section 7000) of Division <br />3 of the Business and Professions Code and my license <br />512268 Expiration Date: 4130103 <br />License #: `_� <br />3) 3 03 contractor: ontractor: _Spectrum Exploration, Inc. <br />Title: _.Operations Manager__ <br />Signature: <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�rkers' 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 />the <br />X I have and will maintain workers' compensation insurance, as required by S compens0a0tion insurance ode <br />for the performance of the work for which this permit is issued. My <br />carrier and policy numbers are: <br />Carrier: _Lumberman's Mutuals <br />Policy Number: 35A16432101-- � <br />employ any <br />rson <br />I certify that in the performance of the work <br />rs co►mpermit tion laws of California, and agree that if I in <br />any manner so as to become subject to the <br />should become subject to the workers' compensation provi ions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date' -3/51/03 Signature: -` <br />Printed Name: Brenda Crawford <br />AND SHALL SUBJECT <br />TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, <br />AN EMPLOYEERR <br />WARNING:FAILURETORIMINAL PENALTIES ANDCIVIL FINE UP T ONE HUNDRED THOUSAND DOLLARS <br />S As <br />($100,000.), IN ADDITION TO THE COST <br />OF THE LAl30R CODE. <br />INTEREST, ATTORNEY'S FEES, AND DAMAGE <br />PROVIDED FOR IN SECTION 3706 <br />AUT ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Ia ord, of Spectrum Exploration, Inc <br />._(signature ofC-57 licensed authorized representative), <br />hereby authorize (print Warne) <br />on on my behalf. I understand this authorization is valid for <br />to sign this San Joaquin County Well Permit Applicati <br />one (1) year and Is limited to the work plan dated on the front page of this 2PP" cation. <br />R-29-021 MI <br />