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SENT BY: SPECTRUM EXPLORATION; 8- 6-99 8:25; 2094658773 => ; p2/2 <br /> } <br /> :IOQADbRESB: _ PERMIT#: <br /> 5 N� OF <br /> LICENSED CONT RAC TORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions 01 Chapter 9(commencing with Section 7000 0!Divi lull <br /> 3 of the Business and Professions Code,and my license is In full force and effect. <br /> Licensee b 122—(Q 8 Expiration Date -30 `Z4001 <br /> Date tractor. (-LLAA � cs cc l lr " `BSc _ <br /> signature <br /> KERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decelerations: <br /> 1:11 have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for b;, <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br /> ❑1 have and wifl maintain workers'compensation Insurance, as required by Section 3700 of the Labcr Code. <br /> for the performance of the work for which this permit is issued. My workers'compensalfon insurance carne( <br /> and policy number are: <br /> Carrier T�. . r tc rrrL; tip{P� Policy Number 5-1 we e— L 5'I <br /> ❑ 1 certify thal in the pedormance of the wink ivr which this permit is Issued, I shall not employ any person In any rnannel <br /> so as to become subject to the workers'compenaa11 of CNiromla,and agree that it I should become subject to <br /> the workers'mrnponsation provisions of Section 300 of Ih Labor Code,1 shell fort Ih cvmpry with thong provlslons <br /> Date— Applicant <br /> i <br /> WARNING:FAILURE TO SECURE WORKERi'COMPENSATION COVER IS UNLAWFUL,AND SHALL SUBJEC T <br /> AN EMPLOYER TO(100,00).IN ADDITION TIO THE COST INAL TOF COMPENSATIOIES AND CIVIL N,DAMAGES AUP TO ONE S PROVIDETHOUSAND <br /> FOR AN 3E outV 3706 Of +I <br /> 7HE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. <br /> s :as-Impim�� <br /> l <br /> JIM 14W.M nr spaetrum[.almatl",1'. <br /> 6llnlu/.cr .'.1M1b wiewain Delve <br /> IIr CA."204 5(Wk,...I•CA <br /> `IpLUp <br /> 2al.ase.e712(rl <br /> 1V'J•IliS Hi)t I;q <br /> ,2eN9r..p„en. <br /> 207 991�1?0mr,r,ounc <br /> . -'l I n r 1 1 1 1 1'1' r• r I 1 I. I <br />