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t, <br />.4 kir)!rill) <br />ci San Joaquin County Environmental Health Department Unit IV Well Permit Applicatio Supplement <br />JOB ADDRESS: MO /06.6/fir-ef--110.4 57 .- PERMIT SR#: beg /Y-91) <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 #: 512268 Expiration Date: 4 β€” 3 0 β€” 0 7 <br />Date: Contractor: Spectrum Exploration, Inc. <br />Signature: 611(1, <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 workers 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 />X 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 />National Union Fire <br />Carrier: Tn qn -ranrp Cnmpany Policy Number: 7 1 7 1 494 <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 />Expiration Date: 4-01 β€”07 Signature: <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 ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHOR1,4ATIQN,,,FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) Riiβ€˜ ft/ifrilWZ <br />Nor <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 application. <br />8-29-02 / MI <br />Title: Location Manager <br />EH D 29-02-001 <br />6/22/04