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JRN-21-2503 16:44 - gEOMRTRIX FRESNO 559 264 7431 P.02/04 <br /> San Joaquin County Envimnmental Healtb Department nit TVPermit Application$upplelrnent <br /> JOB ADDRESS: o r+ o S��c k+-O PERMIT SM <br /> LICENSED CONTRACTORS DECLARATION WO <br /> I hereby affirm that I am Ilcensed under the provisions of Chapter 9(commencing with Section 7000)yr Wsion <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Ocense It �+572268 Expirabon Date.:yM30l03 <br /> ❑ate; i /. 03 Contractor�Spectrurn 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 folloWng declarations' (CHECK ONE) <br /> I have and vAU maintain a certificate of consent#o self-i"W re for v'0r1QU&compensation, as pra►tded for <br /> by Section 3700 of ft Labor Code.for#*perfOMMM6 Of the work for which this pemat 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 far which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Lumbermaft's Mutual Policy Number:38A16432101� <br /> I certify that in the performance of the work for which this permit is issued, l shall not empioy any person in <br /> any manner so as to become subject to the workerV compensation laws of Carifamia, and agree that if I <br /> should beco"su*ctto the worker-V compensation pravrsians of Section 3700 of the Labor Cade, I shall <br /> fortWth comply with those previsions, k <br /> Date:. V-1l 03 Signature: <br /> Printed Name: Brenda Crawford <br /> WARDING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CfjNNNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRIED Th0[JSAND DOLLARS <br /> IN DDI SECTION 37 8 O THE LABORNSATION,INTrzREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED OR <br /> -7 AUTHORIZATION FOR CTHER THAN c-S7 SIGNING PERMIT APPLICATION <br /> 1, ,Brenda CrawFord,of spectrum Exploration,Ina_($19neture ofC-57 licensed authorized representative), <br /> hereby authorize Wnt flame) 0 " GIC a I'l' <br /> a <br /> to sign this Ban Joaquin County Well Perm lt Application an my behalf. I urrdarstand this attthorixation it YIN d for <br /> one(1)year and is limited to the w6rk plan dated an the from PMa or thla applloatlon. <br /> 8-29-02!Ml <br />