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txptoration, Inc 205-465-8773 p. 2 JOB ADDRESS: PERMIT SR#: LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed 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 512768 Expiration Date: _ 04/30/2001 Date: Contractor: Signature: Title: Area Manager Printed name: WORKERS' COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate 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. My workers' compensation insurance carrier and policy numbers are: Carrier- - Slipprior Policy Number: WSN77958—A y I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any 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 forthwith comply with those provisions. Date: �� Signature: Ael� Printed Name: Jim Isle' ldier WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. 1, .Tim Kl ei nfpl clPr of 5nprtrum Expl?ration.. Inc. (C-57 license holder), hereby authorize P"v,' of (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.