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JUN 26 '03 12:18 FR bL�EUINE FRICKE 510 652 4906 �TO 1,W4663433 P.0Nu02 oL <br /> l7b/Gd/G17bd by:G! Gn4b7 +w <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applii:ation Supplement <br /> JOB ADDRESS:C !U• h�a�^�Yn �''� PERMIT SR#: t D3�V2- <br /> 3 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that 1 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: _4!30/05 <br /> Date: Contractor._Spectrum Exploration,Inc. <br /> Signature• /� Tine;_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 sell-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 /> carver and policy numbers are: <br /> Cartier. National Union Fire Insurance Co. Policy Number. #7166639 <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 th a provisions. <br /> Dom; / O Signature: pY� 1 /,t s <br /> / Prirrled Name:_Brenda Crayford <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 /> (3100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, <br /> �THOrRGZAT'ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> of Spectrum Exploration.Inc_Jsign2tum ofCL7 Igoe ed <br /> authorized representative), <br /> herahy authorize(print name) t_ F `- ey', rte Fr I C ice 7/..-P/2�-dt <br /> i <br /> to Sign this San Joaquin County Well Permit Application on my behalf. 1 understand this amhorixation is walld far <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> JUN 23 103 10'27 2094658773 PAGE.02 <br /> ** TOTAL PAGE.02 ** <br />