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Jan 03 01 04: 04p Spectrum Exploration, Inc 209-4Sb-H'r7H p c <br /> 1n� � <br /> i <br /> JOB ADDRESS: 7D nPERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION i(LCD) <br /> I hereby affirm that 1 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 Expiration Date: 04/30/2001 - <br /> Date: Contractor: Inc_ — <br /> Signature; Title: &y&_a Manager <br /> Printed name <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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 3704 of the tabor Code,for the performance of the work for which this permit is issued_ <br /> l 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`oornpensation insurance <br /> carrier and policy numbers are: <br /> Carrier: q111parlor Policy Number: • WSN7 958-A <br /> g•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 it I <br /> should.become subject to the workers'T pen tion provisions of-Section 3700 of the Labor Code,i shall <br /> forthwith.comply with those provisions. <br /> Dame:_ Signature: <br /> Printed Name: Jx e" 1 er <br /> WARNING-FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE 1S UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IDEHE COST OF OF THE LABOR COMPENSATION, <br /> INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION <br /> 1, Xattpnx IP-Q, -(657 license holder),hereby <br /> authorize r of QunC� (7 (consulting),to sign this San <br /> Joaquin County Well Permit.Application on my behalf. I understand this authorization is valid for one(1)year <br /> and is limiled to the work plan dated on the front page of this application. <br />