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12/06/2004 10: 02 2094658773 SPECTRUM EXPLORATION PAGE 01 <br /> Sa,n Joaquin County Environmental Health Department Unit IV Well Permit Applicatlon//--Supplement <br /> JOE ADDRESS: ► 7 q ` r� ►��� ►= PERMIT SR#: �P <br /> (�-�a►v���eEr ���PerfiY� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hemby 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: 4130/05 <br /> Date: I eZ Co dor:_Spectrum Exploration, Inc. <br /> Signature: Title:_Operations Manager <br /> Primed 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 /> 1:.arrier: National Union Fire Insurance Co. Policy Number: 6436303 <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 those provisions. <br /> i <br /> Data: j p-I U I ON _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 /> PR <br /> OVIDED OR <br /> ,000DIN TION TO HE COST <br /> OFTHE OF <br /> FLABOR COMPENSATION,INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> R( <br /> At ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, I rawford,of Spectrum Exploration,Inc._(eignatum ofC-57 licensed authorized representative), <br /> hereby authorize(print name)_-Tn Ir41 0,k, <br /> to a:ign 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 this application. <br /> 8-29-02 f MI <br />