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SENT BY: SPECTRUM; <br />1 - 1 2 - C 9: a9APA; 4e58773 <br />JOB ADDRESS: .6%J - / PERMIT SR#: 60-1 ` <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />1 hereby affirm that I am licensed under the provisions of Chapter o (commencing with Section 7000 of D+vis+u++ <br />3 of the Business and Prcfessiors Code) and my license a in full force and effect <br />License # 512268 Expiration; Date 0413 012 0 0 1 _ <br />Date: jt Contractor: Spm^rUm .xptorat; on, Inc <br />Signature: <br />Title: A_ r� Maqer <br />Printed name: a; m L i4'1 Q i a F- t der _ <br />WORKERS' COMPENSATION DECLARATION <br />i <br />1 hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br />l have and will maintain a certificate of consent to self -insure for workers compensation, as prowuej for r. j <br />Section 3700 of the Labor Code. for the performance of the work for which this permit is issued <br />'I I have and will maintain workers' compensation irs:.trance. as required ny Section S700 of the Labor Code <br />for the performance of the war < for which 'his permit is Issued. My workers' compensation insurance <br />carrier and policy numoers are <br />Carrier: illnPri n Policy Number: WSN77258 .A <br />I certify that in the performance of the work for which this permit is issued. I shall not employ a -,y person :n <br />any manner so as to become subiect to the workers' compensation laws of i✓alrforn+a. and agree that If i <br />should become subject to the workers' cafnp ne i aquon provisions of Section 3700 of the Labor G:rdr;• t shalt <br />terthwith comply with those provlslcns. \ ) , , ,, ' , ,7 <br />i <br />Date: _ �� ��-~�� , ' Signature: <br />Printed Name: /J_m Klei E alder <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSLITION C ERAGE IS UNLAWFUL, ANC SMALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LA50R CODE. <br />i <br />I, .Tim KlP_i_nfnzdr1r nF `ipec Crum ExpinraLioa, InC. (C-57 license hoider),hereby <br />authorizert of f i;/'! '+%1 T FC I1 i�' f r (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 />I <br />and is limited to the work plan dated on the front page of this application. <br />#3'3 <br />