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may 05 00 10: 32a Spectrum Exploration, Inc 209-465-8773 p. 2 <br /> f /�Q <br /> JOB ADDRESS: PERMIT SR#: <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 of the Business and Professions Code)and my license is in fu0 force and effect. <br /> Licerse#: 512266 Expiration Date. 04/30/2001 <br /> Date: Contractor: Spectrin Fvolarat •on Tru _ <br /> Signature: Title: _ Area ttana0 <br /> Printed In <br /> WORKERS' COMPENSATION DECLARATION <br /> j1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> - I :nave 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 /> Carrier: Super inr Policy Number: NSN77958-A <br /> y I certify"hat in the performance of the work for which this permit is issued, I shall not employ any person 1n <br /> any manner so as to become subject to the workers'compensation laws of California, and agree`hat if I <br /> should become subject to the workers' pen tion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 5 5"/YV Signature:_ - <br /> Printed Name:_ Ji a lder _ <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DO.--LARS <br /> ($100,000.).!N ADDITfON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND L.'IMAGE$AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> i <br /> ].__ Tim 91ainfelder of SI - rim EXPIOratiol Ine (C-57 license holder). hereby <br /> c�1 I- 1 <br /> authorize � LY%!!n , of a , nd (consulting),to sign thin San <br /> Joaquin County Well Permit Application on my behalf. I understand this authorization's valid for one(1)year <br /> and!s limited to the work plan dated on the front page of this application. <br />