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• �4 - � �u �3a Spectrum Lxpioration, Inc 209-465-8773 p, 2 <br /> JOB ADDRESS: dee+ PERMIT SRN: <br /> �Tracq, CP- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter S(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#: sl 7268 Expiration Date: 04/3012001 <br /> Date. Contractor:SFpg-rram Explarati011. Inc, <br /> Title: sraA X, na�t�r <br /> Signature: � — <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm tinder penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 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 /> -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- Policy Number: 1wTS 7 95 �A <br /> 1 certify that in the pefformanCe 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 lows of California,and agree that it 1 <br /> should become subject to the workers' pe tion provisions of Section 3700 of the Labor Code, t shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: Dint K e lder <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($jl)o,0D0.h IN ADDION TO SHECOST OF COMP ION,IKT9REST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED OR NECT1W+t f1 O THE DAT <br /> t, � (C-57 license holder),hereby <br /> • of �� iL+- iti <br /> sung),to sign this San <br /> authorlae <br /> Joaquin County Well Permit Application an my behalf, I understand this authorization is valid for one(1)year <br /> and is limited to the work plan dated on the front page of this application. <br />