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01:'22/2003 09:10 2094658773 SPECTRUM EXPLORATION PAGE 01 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />r ' . PERMIT SR#: 3 2 57V?i <br />JOB ADDRESS: <br />XZ-AVIM CA <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I 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 *512260 Expiration Date: 4130103 <br />Date:I Q �J Contractor: _S�ctrum 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 following declarations: (CHECK ONE) <br />— I have and Section 371l maintain a 00 of he Labor Code, for the performanceof consent to nsure for of he work or which this compensation, <br />is issued. <br />ded for <br />by Se <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: Lumberman's Mutual Policy Number: 3BA16432101 <br />I 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 provisio s of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: Signature: <br />Printed Name: Brenda Crawford <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJE <br />CT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, _Brenda Crawford, of Spectrum Exploration, Inc._(signature ofC-57 licensed authfo�rized representative}j <br />hereby authorize (print name) �, d� h is aT <br />o sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br />ne (1) year and is limited to the work plan dated on the front page of this application. <br />I, i :?9-021 MI <br />