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�yl% 10 ul u:�: uup Spectrum Exp. 209-465-8773 p. 2 <br /> i ` <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: ,3J��� jryEp� Ca�>✓ PERMIT SR#: <br /> �QASs SfRecit Kel y Cane,-�Q,; <br /> LICENSED <br /> -- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 C57# 512268 Expiration Date: 04/30/2003 <br /> Date: �1I 6 0I Contractor. Spectrum Exploration Inc <br /> Signature: <br /> Title: Operations Mana er <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,for the performance of the work for which this permit is issued. <br /> XX__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: American Motorist PollcyNumber: 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 prov 'ons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 1 (o 0 I 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 CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),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 /> I Brenda Crawford of Spectrum Explor.(signature ofC-67liceensed authorized representative), <br /> hereby authorize(print name) �� 1S 6- 416 ASWO <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 /> 5-17-2000/MI <br />