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SENT BY: SPECTRUM EXPLORATION; 6-10-99 16:50; 2094658773 => ; #212 <br /> r . <br /> r • <br /> JOB ADdRE33 Ale -PERMIT, - <br /> LICENSED CONTRACTORS DECLARATION <br /> I horeby affirm that I am licensed under b`le provisions of Chapler 8(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code,and my iiense is in full force and effect. <br /> License 0 512-2-G Expiration Dale q-30-ZOO f <br /> Date nlraclor Sjae,,�f L4&41% L4Q�,�t1�()lC - <br /> Slgnatun <br /> KERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peijury one of the following decalarabons' <br /> 0 1 have and will maintain a certificate of consent to self-insure for wo(kers'compensation,as pruvkfed for b,- <br /> Section <br /> ,Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> O 1 have and will maintain workers'compensation insurance, as required by Section 3700 of the tabor Code, <br /> for the performance of the work for which this permit is issued. My wo(kers'compensation Insurance Cartier <br /> and policy number are: <br /> carrier STT- Fy4Z) Policy Number 5� 4�ee-i� 23S1 <br /> 0 1 Certify that In the performance of the work Tor which this permit is issued.I shall not employ any person In any manner <br /> so as to become sub)ed to the workers'compensaU s of California,and agree that If I should become sub)ed to <br /> the workerd compenaetion provisions of Section 3 of Ut Labor Code,I sholl!orttipiilh comply with those provlelons <br /> Dale Applicant <br /> WARNING;FAILURE TO SECURE WORKER6'COMPENSATION COVER 13 UNLAWFUL,AND$HALL SU13JECT <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,DAMAGES A9 PROVIDED FOR IN SECTION 3706 OF <br /> THE LADOR CODE,INTEREST,AND A TTORHEY'S FEES. - ! <br /> ll,n ablalNtlrr, atlticlrum 4ProwtM,IM. <br /> Ala„44„r j34S W�'�Mr O.M <br /> ur A51220 StnUinn,CA <br /> 95205 <br /> 209.469.67321c1 <br /> 209 465.$773 la, <br /> pesd a"094""i" <br /> 709 993.126]mpblu <br /> 411 <br /> 7"d <br />