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SENT BY: SPECTRUM EXPLORATION; 6.18-99 11 :22; 2094658773 => #212 <br /> JOB ADORES& LS/f6 �]• T ICl rl +'C AVC- i' .PERRAIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000 of OIv slvn <br /> 3 of the Business and Professions Cute, and my license is in full force and effect. <br /> License a S t r?2-G p Expiration Date <br /> Date I ntractor �FQL�(fvcvl > ^lilC : <br /> Signature <br /> KERS' COMPENSATION DECLARATION <br /> I hereby affum under pcnailp of perjury one of the following decalarations. <br /> O I 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 far which this permit Is issued <br /> Cl f pave and will maintain workers'compensation Insuranc•.e• as required by Section 3700-1 the Labcr Code, <br /> for the performance of the work for which this permit Is issued. My workers' compensation insurance carrier <br /> and policy number are: <br /> Carrier ITT 4'11 t oV-0 PoticyNumber 51 �ee ��3St <br /> 0 1 caddy char in the performance of eta work kir wnlc h this Permit is Issued, I she#nut employ any person in any manner <br /> so as to become sublect to the workers'cornpensaa of CNllorrda,"agree that if I should become sub)ecl to <br /> the workers'Compeaselion Provisions of Sedbn J 00 of Ih tabor Code,I shalt tort Ih comply with Ithoea pl vvi6luns <br /> Date /pl Applicant _ <br /> WARNING:FAILURE TO SECURE WORKc'Ra"COMPENSATION COVER 13 UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,ODOl,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br /> 7HE IADOR CODE,INTEREST.AND AtTORNEY'S FEES. <br /> ITEC�� „sem�.a.a�► � <br /> a111�♦Lj� <br /> )tm SMInIem., Spectrum EngoMbn.Inc. <br /> Managpr 7105 wigwam Umw <br /> he 951726e SU1%,..n_(► <br /> Tlzvs <br /> ]09.065.6112111 <br /> Inn.ar:r.8713 111. <br /> allafaA6fi**gW*- <br /> 7tri 9911.'07 mann. <br /> -,1 I%T•i 1 11 1'1' i• I":1-I 111 I <br />