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Dec 08 00 12: 39p Spectrum Exploration, Inc 209-465-8773 p. 2 <br /> JOB ADDRESS: 21 4103 elf 1Q 1)(ho Ad' PERMIT SR#: <br /> lL <br /> LICENSED CONTRACTORS DECLARATION (LCd) <br /> 1 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#: 512 be __ Expiration Date: 04/30/2001 <br /> c� <br /> Date: Contractor sPr��n +rnw uxnlo'_,._,., Inc <br /> - <br /> Signature: Title: Area Man g-Q <br /> Printed name: <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 /> 4-1 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: Rup�r i or _Policy Number. wsN77958-A <br /> g 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 subiect to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers pen ion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Iasignature: <br /> Printed Name: Jime' lder <br /> AGE IS UNLAWFUL, � <br /> WAR14ING:FAILURE TO SECURE KERS nON ER <br /> LL <br /> AN EMPLOYER TO CRIMINAL PENAOTES AND CIVIL FINES UP TO ONE HUNDRED THOUSANDDDOILLARSUBJECT <br /> ( N SECTION HE OFST LABOR OFCOMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR ICODE <br /> . nn _ t nc. •( 7 license holder),hereby <br /> f . - r f 4oaw`trUm Exnt oral 1 <br /> I���� ) 1 h {J of "0. F ` [� j��(consulting),to sign this San <br /> authorize 1Jt 1��� .�L��—'�'" <br /> Joaquin County Well Persil pppilcatior on my behalf. 1 understand this authorization is valid for one It 1 year <br /> and is limited to the work plan dated on the front page of this apPlicatlon. — — <br />