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SENT BY: SPECTRUM EXPLORATION; 6.10.92 16:50, 2094658773 #2.'2 <br /> J013 ADORE33-- PERMIT a .V/tr �I <br /> LICENSED CONTRACTORS DECLARATION <br /> I horeby affirm shot I am licensed Under the pr0V13ion9 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 as S 1 2.Z(O S Expiration Dale q-30 -2-001 <br /> Date Contractor �pec,-��ww• �ZC ]lmvrc.t l�'� , u`tc - <br /> i <br /> Slgnatun <br /> KERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of par)ury one of the following decalarations: <br /> ❑ 1 have and will maintain a certificate of consent to self-insure for workers' compensation,as pruvided for b, <br /> Section 3700 of Use Labor Coda,for the performance of the work for which this permit is issued- <br /> 0 1 have and will maintain workers'compensation insurance,as required by Section 3700 of the Lauor 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 17T t� Foy-Z) Policy Number 5 1 wc.c l� 3St <br /> 13 1 cerlity that to the performance of the work Ior which this permit is issued,i shall not empioy any person in any manner <br /> so as to become wbk9d to the workers compo s of Chili=..and agree that if i should becon wb)ect to <br /> the workers corninnsaWn provisions d Sedkm 3 of Ih Lebor Code,1 shah fo "tn 99rrlpty with those provisions <br /> Dale Applicant <br /> WARNING;T-AILURE TO SECURE WORKERS'COMPENSATION COVER44 IS UNLAWFUL,AND SHALL SUBJECT <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 AS PROVIDED FOR IN SECTION 3706 OF <br /> THE LADOR CODE,INTEREST,AND ATTORNEY'S FEES. <br /> nm xrwn[w. fMcb.A.FaOro,Ybn.M,c. <br /> 1/c.95a226A Smtkrm.CA <br /> 9520.4 <br /> 209.465.6712 Iry <br /> I"Af,5 8773 la. <br /> psbdaG&994 lw. <br /> 909 99..1707,,w Av <br /> 7, ',j ta'Vf I r44-P r r'•ra�I nI <br />