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t0 54a Spectrum Exp. <br />San J quin C tyvironn `e-ntai Health Services, U rig <br />JOB ADDRESS: �' t en+ <br />5-10C.K I C4 <br />209-465-9773 p.2 <br />lAt <br />IV Well Permit Application Supplement <br />PERMIT SR#:,01Z dpp?6 <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 #7 C 5 7 P 512268 Ex pi ration Date: 0413012003 <br />Date: <br />Signature: <br />Contractor. Spectrum Exploration, Tnc. <br />Printed name: Brenda( (Crawford <br />Title: Operations Manager <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a ceitificate of consent to seif-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 />:ice_ 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 Prov 'ons of Section 3700 of the Labor Code, 1 shall <br />forthwith comply with those provisions. t <br />Date: 1 vZ;X I j Signature: L <br />Printed Name: Brenda CtAwford <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, ANO SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,090.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND Z.'-,!4AGES AS <br />PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE - <br />1, Bren3a Crawford ofSpectrum Explor-(signatureofC--157r1licensed authorized reprep•=r:itati•a,N., <br />hereby authorize (print name) Luz ius T _a ,t ti oc Iyr I'j'f I 1' <br />to sign this San Joaquin County Well Permit Application on my behalf. 1 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 />6-17-2000 1 Mt -- - — — - -- - - - _ -- <br />