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Dec 01 00 01: 59p Spactrun Exploration, Inc 209-465-8773 p. 2 JOB ADDRESS: OVc&�- 41 W1,197— _ PERMIT SR#: ( A - LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000 of Dlyision 3 of the Business and Professions Code)and my license is in full force and effect. N License#: 512258 Expiration Date: 01/30/2001 s Date: a Contractor: -Sz ar trun Rxplorati on, Inc- Signaturmw Title: Aroa Manager '/rA@*infC]dPr Printed name: Tin WORKERS' COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) _1 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. 1�-I have and wdl 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.— Saptx-r i nr Policy Number:, iI M77958--A i certEfy 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 ers'compensation laws of California, and agree that if I should Dome subject to the workers' n tion provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date: /�"l--Op Signature: Printed Name: i L♦1 Ider WARNING.FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRti'lIINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ADDITIONIN TO THE COST OF ION 37 6 OF THE LABOR C COMPENSATION, INTEREST,ATT'ORNEY'S FEES,AND DAMAGES AS PROVIDED FOR N SE 1, Jim lrl P-i nfebl ag-r n (C-57 license holder),hereby authorizers 17 rof (consulting),to sign this San Joaquin County Well Permit Application on my behalf. I understand th13 authorization is valid for one(t)year and is timitod to the work plan dated on the front page of this application. }