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x08/10/2004 09:21 2094658773 SPECTRUM EXPLORATION PAGE_ 04 <br /> , N a <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS• EAvtl,-k52y &!Q _ PERMIT SRO:,,,5 X11 k3_ <br /> LICENSED CONTRACTORS DECLARATION fl- <br /> l herebyafflrni 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 effeoL <br /> License 512268 Expiration Dana:X4130/0 <br /> []ate: )0-0co alar Spectrum Exploration,Inc. <br /> Signature: Title:Operations Manager <br />! Printed name: Brands Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pe jury one of the follovAng declarations: (CHECK ONE) <br /> Lhava and Wil maintain a certificate of consent to self-Insure for workers'compensatlon,as provided for <br /> by Secilon 3700 of the Labor Code,for the performance of the work for which this pwmlt Is issued. <br /> X-I have and will maintain workers'compan=tIon insurance,as required by Section 3700 of tate Labor Code, <br /> for the performance of the work for which this permit is Issued. My workers'compensation Insurance <br /> carder and policy numbers are: <br /> Carrier._Natlonai Union Fire Insurance Co. Policy Number.6436303 <br /> I ceM that in the performance of the work for which this permit Is Issued,t shall not employ any person in <br /> any manner so as to become sutgect 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 /> forthwithh comply with those provisions. <br /> -- <br /> Daft: .�1�'Q 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 CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,A7-roRNEY'S FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> R ON FOR taT�ER THAN C-67 SIGNING PERMIT APPLICATION <br /> 1, Bre HOrd,of Spedtrum Exploration.Inc.__-(eignaturs afC-67 licensed authorised repressMatrve), <br /> 11 �! <br /> hereby suthofto(print name) ie <br /> I <br /> tv sign this San Joaquin County Wall Perrrntt Applrcitlen an my behalf I undewtmnd this authvrim aman Is valid for <br /> one(1)year and Is lhnited to the work plan dated on On front page of this appilmaon. <br /> 8-�t�02/0111 <br /> RECEIVED TIME AUG. 10, 9: 12AM <br /> I <br />