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SENT 8Y: SPECTRUM EXPLORATION; 7- 1 -99 16:44; 2094658773 => 4!2;2 <br /> JOB ADIJRESS:�4(tr� PERMIT#: <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby afftfm shat 1 em licensed under the provisions of Chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Cade,and my Ncmm is`In full force and effect. <br /> License 061 ?-2-(OS Expiration Date_ "f�30—Z00 f 1 <br /> Date 1' 'g traclor cSyec;� f-LA"A �6dCV Inc _ <br /> Signature_ <br /> �IfgRKERS' COMPENSATION DECLARATION f <br /> 1 hereby affirm under penalz (o/I perjury one of the fowwiny decalaratlon5: `I <br /> O I have and will maintain a certificate of consent to self-insure for rrorkere' comixnsaGon, as provided for by � <br /> Section 3700 of me Labor Code, for the performance of the work for which this permit is Issued. <br /> have and will maintain workers'Compensation insurance,as required by Section 3700 of the Labor <br /> `tor the performance of the work for which this permit Is issued. My workers' compensation Insurance carrier <br /> and policy number are: <br /> Carver 1-77 ♦1 IwIL7C- 0be-t) PolicyNumber <br /> ❑ I certify that in the performance of ere walk fur wnk-h this perrrnt is Issued,I Ulan not employ any person in any manner <br /> so as to becoms subject to the workers'oompan■ .r#CaeWrN■.she agree that If i shouse become subject to <br /> the workers compensation provisions of Section 00 of W Labor Code, I stall fon "Ih comply with those provisions. <br /> Date Applicant <br /> WARNING:FAILURE TO SECURE WORi(FFt&'COMPENSATION COVERr IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (100,WQ),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3701:OF <br /> THE LAOOR CODE,INTEREST.AND ATTORNEY'S FEES. <br /> �tl�:t-�ltuflf� <br /> lYv MINNNNr fysM1,wn E�yMNlat N,c. <br /> Aimuy;.v 2365 wg,.wn 0rov <br /> bc.#512268 !'.k% n.CA <br /> 95205 <br /> 309.K5.■733�.i <br /> IwGr <br /> :'07.93.12[17 ngoAc <br /> - � Iall i <br />