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Feb 08 02 09:46a Spectrum Exp. 209-465-8773 p.3 <br />.•Ey,, <br />:aZ�xx • <br />$an Joaquin County Environmental Health Services, Unit Well Permit Application Supplement <br />JOB ADDRESS: 26 5 ti. - PERMIT SR#: <br />S•�oCllf G ''' <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License <br />C57# 512268 Expiration Date: 04/30/2003 <br />a1= MA <br />Signature: <br />Printed name: Brend <br />Contractor: Spectrum Exploration, Inc. <br />Title: Operations Manager <br />awford <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />Xy._ I have and will maintain wrorkers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier. American Motorist Policy Number: <br />3BG03575800 <br />certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' co4Brenda <br />ions of Section 3700 of the Labor Code, I shall <br />fortfm th 1comply with those provisions. <br />Date: �! g/4� Signature: <br />Printed Name: ford <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$ UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.� IN ADDITION TO OR N SECTION HE COST O T LABOR OFCOMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED <br />I,°'Brenda Crawford of Spectrum Explor .(signature otC""-57 licensed authorized representative), <br />hereby authorize (print name) M Q0 <br />1 ilk r� ti2 1 C� <br />to sign this San Joaquin County Well Permit Application on my behalf. I 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 />7.20001 MI <br />