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Mar 23 00 03: 10p Bre/Spectrum Exploration 209-465-9773 p. 2 JOB ADDRESS:_ r 1� e-4PERMIT SR#: TINGF, LICENSED CONTRACTORS DECLARATION (LCD) I hereby aff im 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#: Expiration Date: 04/30Z2001 Date: Contractor: Expl ration me _..__. Signature: Title: AiCea Ka der _ Printed name: WORKERS' COMPENSATION DECLARATION I 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 selfansure for workers'compensation,as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this permit is issuer!. -X- 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: Policy Number: XS 73q -A -X—I certify that in the performance of the work fear which this permit is issued, I shah not employ any person in any rronner so as to became subject to the worker's'compensatior laws o1 California, and agree that if I should become subject to the workers' pen tion provisions of Section 3700 of the Labor Code, l shall forthwith comply with those provisions. - Date: signature: Printed Name: f m Kee• der WARNING:FAILURE TO SECURE WORKERS'COMPENSATION C RAGE IS UNLAWFUL.AHD SHALL SUB,IEGT AN EWLOYER TO CRI?MNAL PENALTIES AND CML FINES Up TO ONE HUNDRED THOUSAND DOLLARS °. {:104.000.).IN ADDITION TO THE COST OF COMPENSATIOM INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3106 OF THE LABOR CODE_ I, r C- __..(C-57 license holden),hereby authorize c• Of (consul*V),tmg),#o sign this San Joaquin County Well Perm lt Appication on my behalf. I understand this authorization Is valid for one(1)year and Is limited to the work plan dated On the front(sage of this application.