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08/24/2006 17:02 2094658773 SPECTRUM EXPLORATION PAGE 01 <br /> d <br /> AJFI,� % <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: IOG 9D- 1 W., PERMIT SR : <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I e,ereby affirm that i am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 :)f the Business and Professions Code and my license is in full force and effect. <br /> Li,,erase 0: Expiration Date: <br /> Contractor: S ectr= Ex /oration IRS- <br /> Title-. LocatioM <br /> n ona err ._ <br /> Signature• <br /> Printed name: Brenda Crawford <br /> WORKERS'COMPENSATION DECLARATION <br /> I iereby 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 <br /> Carrier: Policy Number 717 1494 <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 /> 15xpiration Date: 4-01 -07 Signature: <br /> Printed Name: Brenda CgAwf d <br /> WARNiNG:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE iS UNLAWFUL,AND SHALL SUBJECT <br /> kN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINSS UP TO ONE HUNDRE13 THOUSAND DOLLARS <br /> ;$100,000.),iN ADDITION To THE COST OF COMPENSATION,INTEREST,ATYORNEY'S FEES,AND DAMAGES AS <br /> ?ROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORiZATION FOR OT ER THAN C-57 SIG=NING PERMIT APPLICATION <br /> I, (signage ofC.67 licensad authorized representative), <br /> hereby authorize(print name} L— <br /> to Sign this San Joaquin County well Permit Application on my behalf, t understand this authorization is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> 9.29.02/M1 <br /> FID 29-02.007 <br /> &2=4 <br />