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09/16/2004 15:48 20946587 SPECTRUM EXPLORATION PAGE 01 <br /> Fiol <br /> n Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> AppRESS: �SLeg <br /> 0� PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (L„ CD,) <br /> I heroby 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#:X512268 Expiration Date: 4130/05 <br /> Date: Ito a Contractor ,Spectrum 1=xploration, Inc, <br /> Signature: Title:,Operations Manager. <br /> Printed name: Brenda Crawford <br /> WORKERS' CQMPENSATION 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 /> Carrier:_National Union Fire Insurance Co. Policy Number: 8436303_ <br /> 1 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= Signature: <br /> Printed Name:! _Brenda Crawford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL, AND SHALL SUBJECT <br /> A� EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($'00,000.),IN ADDITION <br /> 37E COST <br /> THE F COMPENSATION,O�OINTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION <br /> U ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Sre ord,of Spectrum Exploration,inc._(signature ofC-57 I��lce11nsrred authorizedyPregeative), <br /> hureby authorize(print name) <br /> R- ,r [). 'C 1 a <br /> to sign this San Joaquin County Well Permit Application on my behalf. i understand this authorization is valid for <br /> Of le(1)year and is limited to the work plan dated on the front page of this application. <br /> 8.29-021 MI <br />