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7 : <br />JOB ADDRESS: <br /> <br />II fit tdi/S01 <br /> <br />.PERMIT#: 01\0-51 <br /> <br />LICENSED CONTRACTORS DECLARATION <br />3 of tho Business and Professions Code, and my license is in full force and effect. <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br />License I Si 22 S <br />Dote 41111h <br />Signet <br />Expiration Date y-30 - 100 1 <br />ntractor SVQ.C,+- CgiCticv <br />KERS' COMPENSATION DECLARATION <br />hereby affirm under penalty c,f piiijury one of the following decalarabons: <br />I have and will mainlain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />f have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit le issued. My workers' compensation insurance carrier and policy number are: <br />Carrier 1.7-7- t+1"rrt--1- FOLP-Z <br /> <br />Pciftcy Number 51 (-1-)‹. <br /> <br />CI I certify that in the performance of tha work for which this permit is issued, I shall not employ any person in any manner <br />SO as to become subject to the workers' con, of California. and agree that If I should become 94JDOSCS 10 the workers compensation provisions of Section 3 Labor Code, I shall •comply with those provisions. <br />Date g —/ - Applicant <br />WARNING: FAILURE TO SECURE WORAERS' COMPENSATION CO IS UNLAWFUL, AND SHALL SUBJECT 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 THE LABOR CODE, INTEREST, AND A rTORNErS FEES. <br />Mitt <br />SENT BY: SPECTRUM EXPLORATION; 8-16-99 16:03; 2094658773 => <br /> #3/3 <br />_IA11101510 <br />aiNIEF all19.1•11111-441110,459WO AIM <br />7-7 ArArgrollialMr <br />Um's, EMPHillIon. Inc <br />r,5 Dnve simmiiiifirifisk.” CA <br />• <br />209 455.8712 <br />,241,4 4f' sf73 tAx <br />20,19(i i I 11)T ,910Doity <br />I Irf 'I I 1.-1' 1' 0 .) 0 • ) '1