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06/11/2004 16: 24 2094658773 SPECTRUM EXPLORATION PAGE 02 <br /> San Joaquin County Environmental Health Department <br /> D�epaartment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: YGO W 1 PERMIT SR#: 0637 <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#: 512268 Expiration Date:_4130105 <br /> Date: ontractor: _Spectrum Exploration, Inc. <br /> Signature: Title:_Operations Manager <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, 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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 4-11-of 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 CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),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 /> SutRIZATI.CON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1,_Brerd,of Spctrum Exploration, Inc._(signature ofC-57 licensed authorized representative}, <br /> ,C' I ,, :F <br /> hereby authorize(print name)M U�QD T r VI�nP :IrI <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 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 /> 6-294121 MI <br /> AUG 11 104 16:31 2094658773 PAGE.02 <br />