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2094658773 11/08/2605,13:59. <br />v.:) 1 )Pi U • <br />1: r <br />SPECTRUM EXPLORATION PAGE 02 <br />6 Expiration Date: 0 4 — 3 0 — 0 7 License #: 5 <br />Dat e: -05 <br />Contract of Spectrum Exploration, Inc <br />Signature: TRW Regional Manager <br />Prilited name: J irrif P3s1.(ar <br />EFTO '!9•02-001 <br />6/22/04 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 al' the Business and Professions Code and my license is in full force and effect. <br />WORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />x I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit Is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />I certify that In the performance of the work fo <br />any manner so as to become subject to th <br />should become subject to the workers co <br />forthwith comply with those provisions. <br />permit is issued, I shall not employ any person in <br />sation laws of California, and agree that If I <br />ons of Secti n 3700 of the Labor Code, I shall <br />Ex alratIon Date:(14— 1 0-0 7 Signature: <br />Printed Name: ejnfim.lripr <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL 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 LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C.ST SIGNING PERMIT APPLICATION <br />I, ;',"4 m _ KLe 1 .1/.1- / Spec fj Psr r 1 evrp (ollairature ofC-67 licensed authorized representative), <br />hereby authorize (print name) NI KE Vi-Pre-H F001-411.1. eta:4 NEEILI tv. <br />to tign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />on t (1) year and is limited to the work plan dated on the front page of this application. <br />849-02 / MI <br />an Joaquin County Environmental Health Department Unit IV Well Permit Applicatio u plynt <br />JOB ADDRESS: av 5 1.100.3-4i cAuFoo-NiA PERMIT smo: <br />STOC-1v 14 <br />Carrier National Union Fire Polley Number: 11 7 7 8 6 0 <br />rkers' corn <br />ensation provi <br />ITIsura ce mpdny