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JOB ADDRESS: (1/ hi 1,011,C 07 to_y <br /> <br />44 023f(a <br />PERMIT SR#: Sti 6.913, <br /> <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 full force and effect. <br />License* 512268 Expiration Date: 04/30/2001 <br />Date: //ô' Contractor: Spertrum Exoloration- Inc. <br />Signature: Title: Area Manager <br />Printed name: Ji m ei nfelder <br />WORKERS' COMPENSATION DECLARATION <br />I 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 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 />Carrier Superior <br /> <br />Policy Number: <br /> <br />I certify that in the performance of the work for which this permit is 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 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: I 18 10-0 <br />Printed Name: Jim Kleji7lder <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 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 />Jim K pin fp 1 der of Spert rum Exploration. Inc. (C-57 license holder), hereby <br />authorize eg V g3 CPti bti of -tw r n) f M (consulting), to sign this San <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 />Signature: <br />Sep 18 00 03:08p S- -trum Exp1or2atioA, Inc 2C- '65-8773 p . 2