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„oaADDRESS: _- . C%J�,— _�ltt� PEAMiTft:
<br /> UCENSED CONTRACTORS DcC:ARAT1Oh
<br /> 'v ftb)ATIM:hat I an• area under tpa p e's— s.Cr Cnaplar 9('---..-encrtg with Secticn TOGO)of DI•asrxs 3 of this Busvwes and
<br /> rr:'ess.'Jna Coos and my goorlas rsAra bice and OMOCI `
<br /> License I_ � Ex 1rati 1p Date
<br /> Date contractor C i-
<br /> OWNER-BUILDER DECLARATION
<br /> I hereby aft-Ti that I am mxecnpl rear•the Cosa-_Ws L.,*n=.e me foOowtng reason(Secte:r 11a1 5,8,�s,ass a. essicns
<br /> Code. Any:Ay or catasty wi*-Jr requ:ros a:a'-ri1 to mns.! _A, alter. Improv*, semat:sh,or,c pair 8M stn,Ctift :M to Its rasuanra.
<br /> afso r0ovares 7sa a aP"r8t W such pared:!C Re a skan4it stater.ant&at he i5 6rens3s pLrsuartl to Lha prods.ora of Lie C•_r..trdc:a s
<br /> License sw(Chapter 9;xrrmenar,T+.tt Serstan 7C00) of Div-sibn 3 of IAo Ruz:C�,s and Pis etSiOnS Coda;or'hzt he is axonVI
<br /> hi rarer a rho Vass for tt-0 alleged axernpl ett Any vglat.on a SaCton?�3' `,by any apo6eaitt for a Derma s.__scs the applicant
<br /> to a c•. Laity of not rrom than:vo ^jroa IoM rs 45DO)l
<br /> ❑ ;,as 7wra of the prQQWy. n; 1*y E 111,*+yeed vAM way^8a as the:r sa{a comperueaor. w I Co L^.=_ +.�'r,art Cie SL1.,: rc :s rDt
<br /> inter:dec or o.Nww fe,za a Isarzon 7044.Bum' eas and ProfOss+oras Code'Tho wntrxxWs cr so Law does not apply in an
<br /> Owner LK proGerly.-o-,c_lds w improves thereon,and who does suw work?4enaetf ar nraL•gh ^3 owes amp;,yeas,PmOcac that
<br /> Sinn vpovernenls we not intended w a9•e'ed`dr sale t, hawvww. the bcri;0in.3 m irr{.rovement is sold nr r ore yaaf of
<br /> =s ple5an,L v.z vnar-t area:•w.l:ns,.•e the twrc.e.-of arov^rp that Pe cw not t.i+ID or:Tg+ave tv-1-m a•.,+ose of sa:'=e.;
<br /> ❑1,as cw-+v of the proper,.,am nuki&Ne i f,.7a iing wkn censed DDrtratlos to oon2ut,r"pm,ect(Section I sA.3usrsesa and
<br /> Pr=:,r,tpsions Coca ID&PC), The Czt.•r:L;or's License Law aces not app}IC ar owner Of property wt a bte:ds or improves hereon,
<br /> dna Ma oonstr..=far s+.uh pm,ecm wtn a ortU'xtOr(si l:torted,?j--4u;knt A it:e C,n,OT*Ines.rcerna Leen)
<br /> ❑1 ar-aXWWt war SaC Qr, ___... t? r for this mason
<br /> Date: Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> t he,ecy xMirm.nat I para a or IrtWance.ora fed
<br /> Rterenf!tier.'t'on 3W!,_x»r Code) � 1 `
<br /> Expiratsan,Iota ' _-ll Company,_ 's�a^r�..F- :.. _
<br /> CertPl!er!sapy is Re].ne ' _I'_nvtr*r'nenta Heals Ue.artnwR
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE
<br /> Qhis s'zC:xx�_ .4!�Sr'.=•a czrciAtail.t;Loa Ca:rr.t is or oro:lun;!•e= -,IS''}1 of reser
<br /> I re,t'y Inst In t^. erta.^nanx of the v�rtt b w Y+ to s per-r t�5 iss.ar. I sha I not employ any gars-.-in any marnor was to
<br /> became to the Winners'C;rrpersator Laws Of Callon,.
<br /> Dela: Appileant
<br /> NOTICE To APPLICANT f rnaarg P•s Ce,,�€=este Y. =xarnpaon, you shot!d Lae6rne su"a,9�to rhe Worker;'Cgmpe•+serion
<br /> pro-isces of Ole Labor Coca,ycl:mks":ort^, -i raspy will-.i3t pcowwors ar tr:s perrrst”to daerned revolted
<br /> CONSTRUCTION LEND[NG AGENCY
<br /> I trent-`•;,r f r trial Lnem,;a arercy!of tra perto narca c`u e work for vtWW ttsia pwm't is ssued isw-or 3097,
<br /> CN,Good
<br /> Lwweex Mama _.
<br /> Lender's Address
<br /> OMSION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
<br /> ❑ I heret:y cer'.y rat•:o excavehor fixe I5j or Ta"e feet in depin:,x +r,;;b a Gerson is wuired to "Rnr+r-�. nb De made .n
<br /> connector watts vxxU ar9sorizod by the;•e"'r7.aro t'+at no_gild' slrt.Cture,!zc0c'drrg,fatsework,of Gerr•C Lon or dsmar.0;rg
<br /> trsrec', war be mare 7tsn t rty-atx(38;feet high IChattc•3>•Group 2 ArSUe 2,Sec6c i UI Tale 5,Cskfcrn4 Admlyds!.•TSve
<br /> Cr..jdl
<br /> E3 As owner-bu-'fir,i wli rsl ertiouy aryore Ij ca .,+whtC.'',wo[d require a ceTnit f"D.m Ihrr ftr..aOrt of trtdlrstr'wl Seery az nal.od
<br /> abv.e•unless such perscr:has a pemv!:c-D •:c w m fr-err oto drvuvn.
<br /> ❑Diti:;�wr of IndusL,%&Sa'ety Pemut a
<br /> I Card'.ra:• nave read t,s artrr•;.a.xn ar;;state'hat the abt'tin -t-;n»aux, .y cocrea I ag.•ee to:*Ti_,y wt:p ail Grj arra
<br /> W0.1-me9 and state aws^e.aL:;g lea t l Wns?u_^t,act and Cr=_e,e : s'rstarn donstr..l;:tiaon,and hc•e by representatives a L•
<br /> County to ar':er„loon rf o a::,4ue-rrr:rl:^ed prop", for hi,,Nm -,p,-,,C&&3.
<br /> Data Appt[Gant
<br /> EM 43_zz-.A7 -7".5EJ Xh!W_'r0A3_W,:Aawr
<br /> a•Y&.'a
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