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} <br /> "PERMIT# <br /> JOB ADDRESS' <br /> LICcivSED CONTRACTORS DECLARATION <br /> hereby affirm That 1 am licensed under the provisionsnof se sChapter <br /> apain t force(commencing <br /> encingnd .with Section 7000 of Division <br /> 3 of the Business and Professions Code, and my <br /> action Date <br /> _icense# S� Z Z� � � <br /> I t <br /> Date f I ' C ntractor <br /> Signature <br /> KERS' COMPENSATION DECLARATION <br /> hereby affirm under penarr V, pet-'jury one of the following decalarations: ; <br /> ❑ I have anIf-insure for workers' compensation, as Prov <br /> d will maintain a certificafor then perforto se <br /> mance of the work four which this permit s ssued.Ided for b„ i <br /> Section 3700 of the Labor Code, P + � <br /> 7 required by Section 3700 of the Lab <br /> c.- <br /> nave and will maintain workers' compensation insurance, as :.r 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 /> �( Poli Number 5 L,)Ge.�-23S L <br /> Carrier I TT 'T 1 <br /> C 4 certity that in the performance of the work for which this permit is issued. 1 shall not employ any person in any manner <br /> so as to become subject to the workers' compensa7PSATION <br /> of Caliiorrva,and agree that if 1 shoty with thus subject vons. <br /> the workers' compensation provisions of Seclion 3Labor Code. 1 shall fort comply <br /> Q <br /> Date ? 4 i"� ' Applican <br /> i i <br /> 1 WARNING:FAILURE TO SECUF2c WvFtnERS' COtCOVER EIS UNLAWFUL,AND SHALL SUBJECT <br /> IAN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 LABOR CODE,IMT.EREST, AND ATTORNEY'S FEES. <br /> i <br /> t <br /> } <br /> Jim Kleintelder spectrum ExPloration.Inc- <br /> Manager 2365 wigwam Drive <br /> LUc.#512268 Stockton,CA <br /> 95205 i <br /> 209.465.8712 tel <br /> 209.465.87 7 3 fax <br /> 209.993.1207 monde <br /> 1 <br /> 1 <br /> 1 117 1 1 <br />