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..+� UJ L.0 ua: a-re 5peczrum txploration, Inc 2UH-465-8773 P.3 i s •. JOB ADDRESS: �' r4 PERMIT SR#: '-TI' .k LICENSED CONTRACTORS DECLARATION (L_CD} I hereby affirm that l am licensers under the provisions of Chapter 9(commencing with Section 7000 of Division 3 of the Business and Professions Code)and my license is in full force and effect. License 4: Expiration Date, 04 30/2001 _ Date: Contractor sper-ii-rum-Expilaratlign, Inc_ _ signature: Title: Are � � Printed name: WORKERS'COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) t have and will maintain a certfcate of consent to self-insure for workers'compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued_ tiny workers'compensation insurance carrier and policy numbers are: Carrier: superior Policy Number. WSI977958-mit .jL-t certify that in the performance of the work for which this permit is issued, I shall not employ any person in arty manner so as to become subject to the workers'compensation laws of California,and agree that if I should become subject to the workers' pen tion provisions of Section 3700 of the Labor Code,I shall forthwr�hCfc�omply with those proviSWS. 6V Signature: Printed Name: Jim 1der WARNING:FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To CRINNAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORNElr'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. I. _ _ -1 tri nC__- -if,-57 license holder),hereby authorize of sultirrg),to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(1)year and is Limited to the work plan dated on the front}rage of this application.