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ISENT 6Y: SPECTRUM; 12- , v9 5:01PM; 4658773 => 209 838 9883; #2J2 r00 1) tP6 , `` JOB ADDRESS: ��Zo{o�, i`, • �!�s�rr..._...� � ^ PERMIT SR#: 1 LICENSED CONTRACTORS •DECLARATION (LCD) i i hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70UCJ Lf I.)tvls;orti 3 of the Business and Professions Code)and my license is in fUll force and effect License#i _12 _6 Expiration Date •--„_:09/3U/2U1J1 -- - �I Date: i ontrictor: S pe t r UM Exp lora t 10.a, I Signature: .... ______........_—_Title: Area._kJan4ye.r Printed name: .,,_ irit►t.clder _� 4 J WORKERS' COMPENSATION DECLARATION r I hereby affirrn undr:r penalty of perjury vnc of the following declarations. (CHECK ALL THAT APPLY) � I I have and w1l maintain a certificate of consent to self•irsure for worrcers' �rr.pensati�rt, as proviofi6 fear by Ser_tiQn3-7-E1J-cif the Lat w--G da=fe-r-the-parfvrrtranee-of-the-wort%-for-wirict,lh-is-pi fillit-is 1sstf -- j -I have aid w!ll maintain workers'contpensatrun insuronce, as required by Section 3700 of the l_atrxr Crude. for the performance of the work fur which oris permit is issued. My workers' cer]tperlsatrcn ills urar)(,Ie I carrier and P01i0y rurrnbers are: I\ _ .......,.-._-__ Policy Number: WS_N77958_-A • Carrier: SnRe=Yar __.._...................................--- f ,)L_ I certify that in the performance of the work far which this permit is issue(!, I shall not employ i7iny person n; i any manner so as to become subjent to the workerscompensation haws of California. and ogrce that if I i should become subject to the wnrkers' T65Cn tion nrovlsipris of Section 3700 of the Labor Code, i shall i r forthwith comply with those provisions. Date: _.......__-- _ Signature Printed Mame: _ / Jim Klei Ider WARNING: FAILURE TO SECURE WORKERS' COMPENSATION C ERAGE IS UNLAWFUL, Anka SHALL SUDJECT AN EMPLOYER TO CRIMINAL PENALTIFS AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS rSiQt)..000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,AT70RNEY-S FEES,AND DAMAGES AS If PROVIDED FOR IN SECTION 3746 OF THE LABOR CODE. „ I ( 1, Tim K1Pinfn] tiF+ Snr-r-f-.rnm f�_x'J"O�at lOrl. Itl .y i (((//lI 1 p �) O.__..-.. (C•57 license hotderl,hereby auth OrrZe__..,.,...d.0��`.�,T} Y iJ t t 8f /:'1 V 1 r`.f• t - '........:...-...__. _1 C ., (consulting). o sign this San ;j Joayuln Courty lYeell•Pcrrni,"Applicati,.n on my behalf. I(tilderstand this'authorizaLion is'vat;d'for or:e'(f)'i6ar and is Iirnited to the work plan dated on the front page of this application.