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10/0b/2007 11: 46 2094658773 SPECTRUM EXPLORATION PAGE 01 <br /> 2,15-/ ( 6 2,2- <br /> San <br /> ZSan Joaquin covnty EnvironmDeFflirtment Unit Iv Well Permit Application Supplement <br /> JOB ADDRESS:_ 100D� - PERMIT SR#' D L7 7 <br /> STa e-T6r1 05Z10 35 ZEA r <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 irS7 7268 Expiration Date _ 4-30-09 <br /> Dale: Contractor: Spectrum Exploration Inc_ <br /> Signature L Title: Location 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 1 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 /> National Union Fire WC 159 3164 <br /> Carrier:� nce Company Policy Number: <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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. ( �f ''" <br /> Expiration Date: 4-1 -08 Signature: n DJC <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l Y LJ `� Y (signature ofC-67 licensed authorized representative), <br /> hereby authorize(print name) v olu / 4io Lb —GGie— <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 thio application. <br /> 0.2M2 1 MI <br /> rim 79-02 00, <br />