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,I <br /> 09 / 22 / 2006 10 : 05 209465877 -J SPECTRUM EXPLOPI1` 10N PAGE 02 <br /> 4AEI ?& <br /> San Joaquln County Environmental Health Department Unit 19 Well Permit ApPtlea 9n Supplement <br /> JCB ADDRESS: `;�i'% ��'1�76 -�►� PERMIT SR#: rd nj !� <br /> u <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 />'� tirense rG: � a ti12.. - f? — Expiration <br /> Date; 4 - 30 - U7 <br />{ Dat@ Contractor: S ectrum Exploration , Inc .. <br /> Signature: Tithe: Location Mana eT- <br /> 1, PTintedname: Brenda Crawford <br /> i <br /> WORKIwRS' COMPENSATION DECLARATION <br /> I tiereby affirm under penalty of perjury one of the following declarations: (CHECK 01I <br /> _ I have and will maintain a certificate of consent to selfjinsure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work forwhich 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' compensatlon Insurance <br /> carrier and policy numbers are: <br /> National Union fire Policy Number: 717 1494 <br /> Carrier: <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 1 <br /> should become subject to the workers' compensation provisions of Section 3740 of the Labor Code, I shall <br /> forthwith Comply with those provisions- <br /> Fxpiratlon Bate: 44 - 0107 Signature: <br /> Printed Name: Brenda Crawford <br /> bNARNING� FAILURE TO SECURE <br /> ANMPLOYER TO CRIMINAL PENALTIES <br /> AND CML F NES UP TO ONE HUNDRED THOUSKER& COMPENSATION COVERAGE IS AND SUBJECT <br /> N DDOLLARS <br /> {$100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE.. <br /> AUTHORIZATION FOR OTHER THAN C47 SIGNING PERMIT APPLICATION <br /> (signature ofC,-67 licensed authorized representative), <br /> hereby authorize (print nameJ�, <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one (t ) year and is limited to the work plan dated on the front page of We application . <br /> 8-29-021 MI <br /> I e.ao zc-oz-oot <br /> ( 7.2/04 <br />