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SUN 26 '03 10:18 FR LF61-EVINE FRICKE 510 652 4906 TO 1"4683433 P.02i02 <br /> bb!G.iI'Gl1gd ey:e r 6b`J4bm! .erCV I RUM rX4 LIKIW <br /> rmu6 tit <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB ADDRESS:e"' UJ, PERMIT SR# C�03T T-'- <br /> `76/ V003r z� <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 farce and effect. <br /> License#: 512x68 Expiration Date: _4100105 <br /> Date: Contractor._Spectrum Exptoration,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,far the performance of the work for which this permit is issued. <br /> I nave 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 /> caller and policy numbers are: <br /> Carrier: National Union Fire Insurance Co. Policy Number. #7165639 <br /> 1 certify that in the performance of the work for which this permit's 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 provisions. <br /> Date: ) O3 Signature: UI( <br /> ` �� /• Printed Name__Brenda Crawford <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYERTO CRIMINAL,PENALTIES AND CML FINES UP 70 ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,IWERLST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CDDE. <br /> �T�HOrRIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> of Spectrum Explor2gon,Ine._169nature cfC-671iceJ'°�.authwixed representative), <br /> herahyauthorize(printname) LFR l.ev+ne Fr�CKee. <br /> to sign this San Joaquin County Well Permit Application on my Dermalf. 1 understand this authorization is wlld for <br /> one(1)year and is limited to the work plan dated on the front page of this appucation. <br /> 7UN 23 103 10:27 2094658773 PAGE.02 <br /> ** TOTAL PAGE.02 ** <br />