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‘:SENT BY: SPECTRUM EXPLORATION; '6-99 16:03; 2094656773 => X313 <br /> <br />JAIlia1510 <br /> <br />LICENSED CONTRACTORS DECLARATION <br />hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Drvision <br />3 of tho Business and Professions Code, and my kerma is in full force and effect. <br />S t 2.2.(03 <br />KERS' COMPENSATION DECLARATION <br />hereby affirm under penalty a pelfury one of the following decalarabons: <br />0 I have and will maintain a certificate of consent to self-insure for workers' oompensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />o I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code. <br />and policy number are: for the performance of the work for which this permit le issued. My workers' compensation insurance carrier <br />License X <br />Date <br />Signature <br />Expiration Dare <br />ntractor e. (CAAA,._ 4260-tic (jr1 <br />Carrier ITT' 41**rg--1- FOtt-Z) <br />certify that in the performance or the woo k tor wnich 3-0 as to become subject to the workers' corn <br />the workers' cornpensation provisions of Section 3 <br />Date gj 41- <br />Policy Number <br />this pern-tir is issued, I shall not einsikiy any person in any manner <br />Q( California. and agree Mei if I should become subiect to <br />Labor Code, I emit ccornp/), with those provisions <br />Applicant <br />WARNING: FAILURE To SECURE WORXERS' 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 SECTTON 3706 OF THE LABOR CODE, INTEREST, AND A rrcnifitErs FEES. <br />49119.-IN11119.-1•19---,01119-11•Mite991119-41111---411-911-_,pler <br />ZW-AMLIAINCLUYI <br />Jim Kietneeklurr .. Spectrum Emppretiee. pue <br />•"" • '--",“mmitc,—*Pir,f, cuwe <br />LK.. NS 1 711,ti utcm CA <br />4.7tw,wm, .20r, <br />209 445.9712 ft.( <br />4fi`, 77 3R C. <br />COq 79.i I All moDae <br />11 -1%1 I I I. 1, r . I Ii,