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09116/2004 15: 40 2094658773 SPECTRUM EXPLORATION PAGE 01 <br /> Sa n Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: <br /> $ b5'1 <br /> bI wl �� `>Jb1kQk PERMIT Std#: �J 4. <br /> LICENSED CONTRACTORS DECLARATION <br /> I heroby affirm that nd Professions Code and provisions <br /> my license is Chapter force a d effect_with Section 7000)of Division <br /> 3 of the Business <br /> License#:-512268_________.Expiration Date: __#30105 <br /> Date; �✓T4 Contractor: Spectrum Exploration, Inc. <br /> Tdlet,Operatlons Manager <br /> Signature: <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 /> Carrier: National Union Fire Insurance Co.-policy Number:6436303. <br /> 1 certify that in the performance of the work for which this permit is issued, l 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 /> Da te: Signature: <br /> Printed Name: Brenda Crawford <br /> W/�RNING: FAILURE TO SECURE WORKERS'COMPENSA-nON COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AW EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($'00,000.),IN ADDITIONTO 3706 OF THE OF <br /> FLAEOR COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PF,OVIDED FOR IN SECTION <br /> U ORIZATION FOR OTHiE14 THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Bre rd,of Spectrum Exploration,inc—(Signature ofC-57 licensed authorized representative), <br /> - i 1t C, i <br /> hereby authorize(print name) cc. V �: U L�� <br /> to sign tfils San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> o,ie(1)year and is limited to the work pian dated on the front page of this application. <br /> S•2"2JMI <br />