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?rA4i; 20'34b7tl/13 SPECTRUM EXPLORATION PAGE 91 <br /> oe- <br /> San Joaquin CoOnty Ennvironnme tal Health De rtment Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:_ �Or]Qct !3 PERMIT SR#' 507up <br /> Srl <br /> LICENSED CONTRACTORS DECLARATION (LCA) <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 Tome and effect. <br /> License# 517268 - _ ExpirationDate,_ 4-30-09 <br /> Date: Contractor: Spectrum Exploration Inc- <br /> Signature: , 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 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 /> National Union Fire WC 159 3164 <br /> Carrier: Tncnranro Cnmpan_y Polity 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. <br /> Expiration Date: 4-1-08 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 /> 15100,000-),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 OWER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, eurar <br /> (signature ofC.til licensed authorized representative), <br /> hereby authorize(print name) 0,Ai / 4iol c) <br /> to sign this San Joaquin County Well Permit Application on my behair. 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 /> 0-29-02 1 MI <br /> r,rn w-m.00, <br />