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SENT BY: SPECTRUM EXPLORATION; 9-21-99 14:39; 2094658773 => 209 838 9883; #2/2 <br />JOB ADDRESS: VO° • ftVi'l PERMIT SR#: 0 ZO 656 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (Lommericihy 1000 01 DAasion <br />3 of the Business and ProfessiOns Code) and my license is in full force and effect <br />4' <br />I.icerise # <br />Date: <br />Signature: <br />Printed name: <br /> Explialicm Date 04/30/2001, <br />C;tmtriwtor puctzum Exploration. <br />Title: Area Manager <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm tinder penalty of perjury one of he folloviang declarations (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-insure for workers' compe fThadfirl. as i.;rovicied for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit 15 issued <br />I have and will maintain workers' compensation required by Section 3700 of the L:Aboi Code, <br />for the performance of the work fui which this permit is issued. My workers' compemiation iii!;branCe <br />carrier and policy numbers are <br />Carrier; Su poriar Policy Number: WSN77958- A <br />y certify that in the performance of the work for which this permit •s issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if <br />should become subject to the workers' cteipen. •ition provisions of Section 3700 of the Labor Code.. shi0 <br />forthwith comply with those previsions \s, <br />Date: gle:P ! /99 Signature: <br />Printed Name: J,.Kle Lder <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION C ERAGE IS UNLAWFUL. AND SHALL SUl3JEC 7 <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONF HUNDRED THOUSAND DOLLARS <br />($100,044.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S rr.s. AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />L dim Kl pi nfplrior iL LI:pc:L:11r um. Exploxal. ion Inc . {C-57 license tioider), hereb}i <br />atithOrize_..2:0Thn ti or _____ (consulting), to sign this San e <br />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 plan dated on the front page of this application. <br />3R 002,0C-6(0