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SENT BY: SPECTRUM, 1 -12 0 9:49Aeai 4UpbIiZ <br /> i <br /> L01 <br /> JOB ADDRESS: �/� C. / / PERMIT SR#: 5;L1 l ` �e <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter o (commencing with Section 7000 of Divisiun <br /> 3 of the Business and Professions Code) and my license is in full force and effect <br /> License#: 5177Fa Expiration Date 04/30/2001 _- <br /> IDate: Contractor: slpoc-tr im Fxntoration , IrtC , - <br /> Signature: Title: Area Manager <br /> Printed name: <br /> 1 <br /> WORKERS` COMPENSATION DECLARATION <br /> 1 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 provwed for h/ <br /> Section 3700 of the Labor Code. for the performance of the work for which this permit is issued <br /> I <br /> _ I have and will maintain workersCompensation insurance. as required by Section 3700 of the Lacor Cade <br /> for the performance of the work for which this permit is Issued. My workers' compensation insurance <br /> carrier and policy nurnoers are <br /> Carrier: snp ;or Policy Number: WSN77258 -A <br /> i <br /> i <br /> x_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 sub iect to the workers" Compensation laws of California. and agree that if I <br /> should become sub)ecf to the workers' cafnppen'batron provisions of Section 3700 of the Labor Cade, l shall <br /> forthwith comply with those provisicns \ , <br /> I <br /> Date: _ 1 la -: U! Signature: <br /> Printed Name: / Jim i f'4der <br /> J - <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION C /ER AGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.1, 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 /> 1, .Tim H7p,' nro1dr-r nr Spc+r-trum Rx lora inn, Inc . (c-57 license holder). hereby <br /> r <br /> I authorize .Jf/I7n If Jt of _(consulting), to sign this San <br /> i Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1)year <br /> and is limited to the work pian dated on the front page of this application. <br />