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Jun 13 00 08: 07a Sp--'*Itrum Exploration, Inc 20F '65-87`i3 PERMIT SR#: D% FJOBADDRESS: I3I4 64 X�, LICENSED CONTRACTORS DECLARATION (LCD) that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Divisess and Professions Code) and my license is in full force and effect. #. Expiration Date: 04/30 License /2001 Date: Contractor: Title: - Signature: Printed name: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHI=CK ALL THAT APPLY) ers' compensation, as I ection 3700d 1of the Labor Code, for the performanceof consent to f-insure for of the work forkwhich this permit s issued, for by S 0 of I have and will ncetof the work for which thin workers' is permition isce, as issued. My workers' compenequired by Seution sationthe insu ab ceor Code, i for the perform carrier and policy numbers are: Carrier: Policy Number: _ WSN779587A _ I certify that in the performance of the work for which this permit is issued, I shalt not employ L-�r- any manner so as to become subject to the workers' compensation laws of California, and agEet should become subject to the workers' pen tion provisions of Section 3700 of the forthwith comply with those provisions. Date:, /� Signature: -..— - Printed Name: Jim Kle' WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL. . AN EMPLO IN ADDITION R TO INAL TO THE COSCIVILIES AND T OF COMPEN COMPENSATION,INTEREST,AP To ONE TTORNEY STHOUSANDDRED EES,AND UA.. - PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. rum ExPC_ (C-57 license holder), hereby I. authorize eel'` of kro4 yi �6L (consulting),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 page of this application. E