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08/25/2006 07:46 6613255JI13 GUINN CONSTRUCT111111111110 '12N PAGE 03 <br /> 08/24/2006 17:06 20946 3 SPECTRUM EXPLaMON PAGE 02 <br /> w <br /> A-7Tt� <br /> nM 0, C � <br /> San Joaquin County Environmental Health Niparbwt Unit IV Well Permit AppllaWon Supplement <br /> JCB ADDRESS: 10W N I N6 1 PERMIT So: <br /> LICENSED CONTRACTORS DECLARATION ) <br /> I hereby arm that I am licensed under the provisions of Chapter 8(commencing with Section 7000)of 01413ion <br /> 3 of the Business and Professions Code and my license is in full force and . <br /> License* 512,208 E,xplratlan Date,• --A-30-07 <br /> Date: !7z Contractor: SRQ2trum Ex. 10rR tion■ Inc. <br /> znc.. ...,�® <br /> Signature: "title: Wcetion Manager <br /> Printed name: SIrenda Crawford <br /> WORKERS' COMPENSATION DECLARATION <br /> I mereby affirm under penalty of p"uty one of the following daofaraf ms: (CHECK ONE) <br /> _®I have and will maintain a cartificate of consent to sOINnsure for workers'comps tion,as provided for <br /> by Section 3700 of the Labor Code,for ft performance of the work for which this permit Is Issued. <br /> _X I have and will maintain workers'cornpens;IWn 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'txtmpansetion insurance <br /> carrier and policy numbers are: <br /> National Urian Fire <br /> CBrder: Xnallin oms ang Policy Number. 71? 1494 <br /> I certify that in the peftrmance of the work fbr which this permit is issued.I shell not employ any person in <br /> any Manner so as to became subject to the workers'compensetion laws of Califamis,and agme that if I <br /> should become subject to the workam'comperisMon provisions of Sadao 3700 of time Labor Code,I shall <br /> farthwith comply with those provisions. <br /> Eviration IDRIte: 4-01-07 Signature: <br /> Printed Name: Brenda Crawford <br /> WARNING,FAILURE TO SECURE WORKERS,COMPENSATION COVERAGM IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML,FINES UP TO ONE HUNDRED TWOUSAND DOLLARS <br /> (r.100,000.).IN ABOMON TO THE COST OF COMPENSATION,INTEREST,ATTORNE-PS FEIaS,AND DAMJACES AS <br /> PROVIDED FOR IN SECTION 8706 OF THE LA80R CODE. <br /> AUTHORIZATION FOR O ER THAN C-57 SIGNINQ PERMIT APPLICATION <br /> b (Signature afC4 97 licensed atrlhortd represerifttivVil.. <br /> bemby"alike(print narnel Vr.QL!aDf-UC-nQ,&, <br /> to sign this;fiery-Immuln Caunrty Well Permit Application®n my behalf. I understand thIS autherttation le valid for <br /> one(1)year and Is IImNIad to she work plan dated on the front page of this application <br /> €•29,42 J III <br /> VIM)Z90401 <br /> 612::104 <br />