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'Oct 23 01 10: 54a Spectrum Exp. 209-465-8773 p- 2 <br /> San J qu?C�ty Ironm``erNal Health Services, U N Well Pemtlt Application Supplement <br /> JOB ADDRESS: i Ce+ PERMIT SR#:XZ d, /p_ <br /> 5--b 1 (14 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm timet 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 C57# 512268 Expiration Date: 04/30/2003 <br /> Date: 10 1:17.16 1 Contractor. Spectrum Exploration, Inc. <br /> Signature: Title: Operations Manager <br /> Printed name: Brenda rawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _ I have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,forthe performance of the work for which this permit is issued. <br /> XX_I have and YAR 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.. American Motorist Policy Number- 3BG03575800 <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 provIgons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions_ <br /> Date: 10 l a;L 'O 1 Signature: <br /> Printed Name: Brenda Ct&wford <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO DNE HUNDRED THOUSAND DOLLARS <br /> 55100,000.1,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 /> 1 Brenda Crawford of Spectrum Exlplor-(signature un;57 licensed l `authorized representative, <br /> hereby authorize(print name) W,t cls : Iter o m`C,4-2 tri M� I 1 f I <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 /> 5-17.200010 <br />