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Jan-12-00 20: 39 P_02 <br /> acne Dy. UOV cal ra�c� van r� i ac. �rnn� raytl Cr[ <br /> I <br /> JOB ADDRESS: PERMIrI <br /> f <br /> LICENSED CONTRACTORS DECLARAT1 )N <br /> I hereby affirm that i am licensed under the provisions of Chapter 9 (commencing wit Section 7000 of Division <br /> 3 of the Business and Professions Code, and my license is In full force and effect. <br /> License# C57 552198 Expiration Date 6/30/01 <br /> PWM 1/12/00 Contractor western Strata Explorat .on, Inc. <br /> Signature <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: <br /> I have and will maintain a certficale of consent to self-insure for workers'compens ition, as provided for by <br /> Section 3700 of the Labor Code.fpr the performance of the work for which this pe nit is Issued. I! <br /> I have and will maintain workers'Compensation insurance, as required by Section' 700 of the Labor Code, <br /> for the perbrmance Of the work for which this permit is issued. My workers'comp nsation insurance carrier <br /> and policy number are: <br /> Carrier Golden Eagle Iris. Policy Number JMWC548220- 10 <br /> I cerilfy that in the Perfarmanpe of the work for which this permit is issued. I shall n it employ any person in <br /> any manner so as to become subject to the workers'rampensation laws of Califor ilk,and agree th4at If 1 <br /> snewtl become suDjeGt to the workers' Campansation pT�Ip�ons of Section 37p0 s �Cf�e Labor Ce, I shall <br /> forthwith comply with those provisions, <br /> 1/12/00 <br /> Date Signature: <br /> WARNING_FAILURE TO SECURE WORKEfiS COMPF,f�5A71aN COV GE tJNI.A ,AND SHALL$Lrt3Jt;C7 <br /> AN EMPLOYER TO CRIMINAL PENALTIES D CIVIC FINES UP TO NE HIdNDRED T JSAND DOLLARS <br /> (100,000),IN ADDITION TO THE COST OF M!5.Efi1SATION,DAMA ES AA PROVIDE � )RIN SECTION 3706 OF <br /> THE LABOR COOL INTEREST.AND ATTO NEY'S FEES. <br /> I <br />