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1'LI bb/L17b4 1 b:bL Ln74b�t9/ ' ort i Buri cnrLUMi-1- wn rHuc ui <br /> Sa,n Joaquin County Environmental Health Department Unit fV Well Permit Application Supplement <br /> PERMIT SR#: 0 CSuC <br /> JOE, ADDRESS: 1 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I heroby 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 effact. <br /> License#: 512268 Expiration Date; 4130105 <br /> Date; I e; Co ctor:_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 /> Carrier: _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 /> Date: I oZ OL1 Signature: <br /> Printed Name: Brenda Crawford <br /> WA11NIING: 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 /> PROVIDED FOR N SECTION 37 6 <br /> ,IN ADDITION TO THE COF THE OF <br /> FLABOR COMPENSATION; <br /> ATION; INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> R( <br /> A ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> trum Exploration,Inc.�(sis�nature ofC-57 licensed authorized representative), <br /> I, I rawford,of Spec p I <br /> hereby authorize(print name),_ Y1�8 <br /> to;:ign this San Joaquin COunty Well Permit Appiication on my behalf. I under_{and 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 /> 8-2"2 r MI <br />