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ntractor: Spectrum Exploration, Inc. <br />Title: Operations Manager_ <br />3 <br />A 11f-11W-2603 16 : 44 GEOMATR I X FRESNO 559 264 7431 P.02/04 <br />ari/ VI-- <br />6 a n Joaquin County Environmental Health Department nit IV 'ell Permit Application Supplement <br />JOB ADDRESS: Fo <br />PERMIT SR#: 6103thA <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />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 #: 512268 Expiration Date: 4/30ro3 <br />Date: <br />Signature: <br />Printed name: Brenda Crawford <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />(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 <br />issued. <br />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: _Lumberman's Mutual Policy Number; 3BA16432101 <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. <br />Date: V-1-1 /03 Signature: <br /> <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 CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION n06 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, _Brenda Crawford, of Spectrum Exploration, Inc._(signature ofC-57 licensed authorized represenb3tive), <br />hereby authorize (print name) — a e 8 o vt. <br />to sign this San Joaquin County Well Permit Application on 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 appilcation. <br />849-02 / MI