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<br /> I Pp1WITa:
<br /> fOBADYRi_Sfi
<br /> I.ICEN''SED CONTRACT OAS TECLARA'[ION
<br /> (hetthy a[fmn rlu[i am)wen ed mulct lEc alC'hxplar 9 feemealsern6 nyld lk tioh%tal,of Untisian 3 ofehe Du.mess
<br /> mid Prot .neem Code add my Slonnc ai en 1411 rote and cffcel
<br /> IJceve a Eirplaalims Date
<br /> pnh Cmnuaewr _
<br /> O\YNER-BLTLD£R DLCLARATTON
<br /> I hereby affem Ihre I em,ecclrpl from the Cuntraner's LLCM+ sao fur the fisltowmW seeron 1Stcmw 7031 S. pusle.ss and
<br /> Pmfravaru Code: Any axmry whtah tNmrav a permit to cme ri i i.al<:,m4^:mrc,dpmlish,or x,,Aroiry.tnxhue,prim re
<br /> it,us.a 'acus tequics:he wpptrcros Gx such pcemrt[u lite a itv"stet rcwl shy&h.n Iicesed pu,w:m to the pemvloos of the
<br /> Comraaai a fuemse Law(flievW9(aonlmxi>•in3 wldi Saceido VJG)of Divtsioo}of the Diuinevi aewi Prilsojii s['vdcl me that he
<br /> is.xnnrl Ilntflolm AW die lix"I for tlw aEagad e[HllpIWII- Any 1.01el ei of Smtlom'W4 5 by Jey'Irld s foe s psmlel suSidech
<br /> dx applicaest to ae,.1M.Ity cimor nam nhan Grc hamtrcJ dollars(S(SW)
<br /> 17 1,ro mucus of the property,cc m2 cot,6 l es with wages a&wff sole cmepecsaaon•ws0 do die work.eIA Thr.sdeleben u nal
<br /> mtehd,d or offered flit sale(Sechurt'03a,Irmmeii end Pmfesvvm Cade:yl.camitussr,License Paw does mat apply[a an ower
<br /> N¢eupmy wN builds to Impmyc.:M1neoa,add who does.such wok tvmsetr or eluauph his owo eoployats,ptavided Ihat such
<br /> "ovana-h avc nml unaided or m IM for sale. Ir,howc+a.the bufldiu7 or irtpruvcmanc ss sold%wlissi ax frar of<wWlchud.
<br /> thr awe.lit ildcc will base the bmderof ncm,hy Thee be did iwl lvadd m irtdmra<rm IN,porpou of sale.)
<br /> O 1,as waster or the prep,—.y,am caclvlvely cmnhacimg aslh llceoud c-r+- tmrs w eamiracl de fwlect(Sr:aion)Via,Dusine l
<br /> aiW Au&wives Cauda STLtPC?: 'llv:Cmnmxtar's Llarnse l.aw•does owl appy m oe owner nfpraperrywh M1<ib11 m irnprova F.eeeon,
<br /> rad who rn65lrurRa fm such?"'Was.""b a convacmrlsl kc eed pwwan:ro the C.Io. cmr Lxeru Law i
<br /> O 1 wen exempt nr-drr Section_- -, HAK fm eters naso[
<br /> Oates Osm.r
<br /> wuFmcRS'CO?SPF.Nmuo r pECLARATiaN
<br /> I heveby affllm dhael haaw 1CZRr7ieetC mfCgl'bctlr!a Klr'IPSmc Aaecldleate Of l'••'911riii Cvmpni�aham Lwml'a.Y.c.ar a4eFl]fled
<br /> copy[hereof fSernon 3SW,Labor(We).
<br /> £apintimhase—__ C.eri
<br /> O C'ciLf.eJ copy n hsrehy hrto itt,'J
<br /> O Camfird copyse filed w,Ib the h'rtvimfmwl:ul 0111dl pepanrMI
<br /> CERTIFICATE OF h:)t£NIPI70N VROIII w•ORAERS'CONP£NSATION t%SLIRA.xCE
<br /> JI j�'hi:weo,.g",lW,-1�- nific-d'uh,Wrisn_IilJLrc hu AtALylgJ]inI51+?G}Sr lc.<s)
<br /> 1certify Bul so[he pev .r .Cmafchehr wSichelm pCms11..issued,[+? II matm�b)Y onY'6xaassnivany mnmatw as so
<br /> JI beemrc mbM to rhe Wu'esReos' icpemasuc o[sws a[Cib1 rnn
<br /> Due: Appilmot__ _
<br /> NOTICE TO APPLICANT If nr Dar . ki.9 this L'ultfxax : UrJgi y» lsauld become wbyin to the iV.4ol'
<br /> Cnapensr,Ignlu^vuionssd O:[ahai i:odl,3avmillfna!hralh cmremly wvlh sixhprmviaro ar Vnsperrtdl shah be de.nlad revakeiL
<br /> JCONSI'ADCITION 11NIa1NG A"-NCV
<br /> I h.eeby affirm ihsc Ane is a comm clieri rrndutg ancooy fec:bc p,,f.nce of the work for which th:1 p.emil 1.issued fSectime
<br /> 3097.Civil Cadet.
<br /> Lend."Address
<br /> I pI VIS1oN of uNlxstWAl,sASET-r PERAsrt CEiI rtCAnoN
<br /> l G B'..by ccl,fy dut nm.xcavehon lure 0 or root[ fee,or depth its.which.puuon is regmmd to descecd,wiD be nude m
<br /> cuseae,inn"h wank vmbarroad by dt.mi a ir.and Iht no bmid,ng simotera.wxffoldhlvs,fals.sa. L.oe derrcd dim ms dnnwnlEnx
<br /> tbexof,erdl be mote tlha flmi'Lws lad)fim h•rh(Clmpn?2.Gmiip 2,Aroclt P.C.eeldn W.,Thle W,Cakfemin Adreellmm:ve
<br /> Cafe}
<br /> C3 As owmt+dlloti.I wih row riwlns myii c w do wok which would re9uuc a p Al from Ibv Dwietcn of sndisstsrel Safvy,m
<br /> nmol abase uii.4ss such person hes a[r:ilio m d>such wxk from d::dirtvan
<br /> O pmnma ul Imdwsvu7 Safety Pinmi y _ ___ _ _
<br /> 1 cemP that I sure read rhos applF.meo ani sane ds dw abase nalmrmedort n wriec: t agree w cdfvty wwh 011:uy and e,.sm[y
<br /> mdiw.cs end era[[laws xlwmg 1w w•rll cmltrmmve ml or uwavt gxrem.....lion,c9 Gsehy cothoeve mpitn.nmhves of ibr
<br /> QO.sty Nenxr.T] l to iruyr.liOfl puepomi
<br /> Dare Applleame
<br /> fllDalp:{Ii+
<br /> %I"'M it Wi MYll pumsaa' KY+fwive+�.m
<br /> )/2011
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