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SENT BY: SPECTRUM EXPLORATION; 8-16-99 16:03; 2094658773 => <br /> <br />#3 / 3 <br />.PERoirr#:_agj <br />LICENSED CONTRACTORS DECLARATION <br />1 hereby affirm 'heti am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br />3 of tho Business and Professions Code, and my license is in full force and effect. <br />License #S 21 S Expiration Date <br />Dole <br />ntractor 'Sp e r - r(..A.A&A_ Jitic _ <br />KERS COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury One Of the following decalarabons: <br />ID I have and will mainlaln <br />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 />1:1 I hove and <br />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 is issued. My workers' compensallon insurance carrier <br />Carrier 1:1-T tAlorptt Let) Policy Number <br />cettify that in the performance of the wok for which this permit is issued, I shall net employ spy person in any manner so as to become subject to the workers' compansati of California. and agree that ill should become subleci to the workers' compensation provisions of Section 3 QOc,f Lebor Code, I shall •th comply with those provisions <br />WARNING: FAILURE TO SECURE WORXERS' COMPENSATION COVER IIS UNLAWFUL, AND SHALL SUBJECT <br />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 utooR CODE, INTEREST, AND A l'TORNErS FEES. <br />al1M-dia164M10-491/1941...0119*-4.-.01/11111F—alla <br />T77,i2P--1:111V;r1jR <br />Jim kleinlelden EcOorallon. Inc <br />WIKVeriltI I <br />St M "I'.'" CA <br />209 495.9712 Tr <br />41(;`, fi 7 7 3 <br />'201 9' i ) mot)111. <br />1"- <br />jOB ADDRESS: <br />Signature <br />Date g1b- 99 Applicant