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Rug OS 02 11 : 09a Sp--arum Exp. 2P�-465-8773 p. 2 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS) Q 1an� 33 PERMIT SR#: O�J3DS <br /> { Q+ Pin n4yR+� �o3L,s�L <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 /> License# C570 512268 Expiration Date: 04/30/2003 <br /> Date: S �a Contractor. Spectrum Exploration, Inc. f <br /> Signature Title: operations Manager <br /> Printed name Brenda rawford <br /> r 4 <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,for the performance of the work for which this permit is issued. <br /> d <br /> 1 Have and will maintain workers'compensation Insurance, as required by Section 3700 of the Labor Cade. <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance � <br /> carrier and policy numbers are: <br /> Cartier. American Motorist Policy Number: 3BG03575800 <br /> _t 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 prov one of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> i <br /> Date• /S, D 7-- Signature; <br /> Printed Name: Brenda C wford <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 /> (i100,000.� 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 /> r 7yi, 1_'BYenda Crawford of Spectrum Explor.(slgnature ofC-671cermed horized representauve). <br /> `'" � 111!5 0 >'Sl2i >11 e)rd Qt2 77�L <br /> R hereby authorize(print nam <br /> i 1 tosign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> ,. <br /> one(1)year and ie limited to the work plan dated on the front page of this application. <br /> i <br /> 6.17,20001 MI <br /> {I rlU <br /> k <br />