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Page 19 of 51
<br /> Jon Ao9PY_c5:__�__ _ Pralnrt ng
<br /> L.ICT-NS"CONTRACTORS DECL.VICA3'ION
<br /> I Wrby 41fmn lhm l am In,mwd ruder be pwvllmrrs of Chapter 9 icam®ennnR w:N Stebbo 71W)Of Djs.rgn i of the Puyms:t5
<br /> nod Profevimn Cede noa nn,Ii oon.u m full fmce and erka
<br /> umnea —.�_-z_ Erplrklfom Date__—m— a
<br /> nage Centfac/er yz
<br /> OVAiYER-Bll[LDEK DEC LARATION
<br /> I hereby albnh!b: L am n<eltgrl ffhdt the COtnacwt'r U"It'V Law IJ the INIn-Iog reaavn(SNivn 703l.S, R.11u ant
<br /> Frv&ararm C:alr Any eiry 9r n.nrY whl(II ralruree v pcmdr la c+.;deacb aIle,Iml%me,demalbh,or esl+vr My u9velvle,pnm b
<br /> in IrrlFttge,51W tCquiM LA nppli4ar:for 5',h'b pgamt 19 file a gjgr,Cd Om lmgnt elu[he u ltm cd pvmaaal to 4r om•miou of the
<br /> [:'anaancw'v Licelue U.ICb ffee 9(n mme-.9 with Sec"m 70+00)of Dwonom 3 of the Dloarmc s all PmR wm Cod:}or rhal Ire
<br /> ty e.mpl hemrwm vnd dw bass rm ihC.11490!evemp:ion. Any vi dan9n of 5ecdvn id31 5 by nay appbcant Carr a.panne sub)mh
<br /> the applleant to a 9vd penalty ofnol mre dw Ave hundred dv7ms(03034
<br /> O I,sf a. o,of tln paapetly,nr my arylovm"Al wages vs thew sale wan.gna:i9n,"AL A9 Urn wort, Od the rnuclure rs nn:
<br /> mended m 9ffcmd for s!.-(S[Ction 1044,Blow,and Pfafes&:Om Code:1'he cantrvcloi e l wenn Law darn wg apply m an.nner
<br /> of promly wbP blinds m Imptonr ;bm rat1, 'LAI' M'Im deer Imb wwk vinocil or%rough hl$ on Fn•{ikD .,Pmeded$IWr MA
<br /> _ InglvaYeufealr a[c nal InlearlN ev aflcY.d Cqr seL!. If)mn%e:lt,the bml&mg oe el"nveHN1A n 941:0 widan one year of conVichon.
<br /> the our .toBdee%J)nn"the leaden ul%.ring di he Ad ort bmld or laquave(Or dne(Vupow of sale/
<br /> L3 I,ss awur of dm pmP",am exclmrn'cly embveemg wsdr h."canWcfo a le o,nnma:t Ilk pn+jdu(5nedm i 4144,kWu,Yw!
<br /> mrd Profenwrm COdr t8&rCV'. 33e c'vlmaswr'r Jxcnu taw den nm vpply man of p w. who buel,A n,:IPprosx,-hemun.
<br /> and wkO wlrsrmcer fw 4ch prNA[s wah a gamacml(ay IiesAud pyts.ane:o Ur'Cnn'r MW,1 Y9r'6 Ligenu Isw.1
<br /> Cl f nm exrmpt under 8egnom- _ mAQIrC for das rO ur.
<br /> Dale. Owner
<br /> WORKERS'COMPENSATION DECLARATION
<br /> 9 bendy aKrm Iia:a Favca.xiEicvtc aCcvnsnl m r 16ins+oe xa cMiC¢ale of W'uke.�Cbll;eamlwn lnluvartcc,or v cUufxd
<br /> eapy 1110roof(Sorg%3800,Iatar(W4)
<br /> Espltadon Date Cumpvmy
<br /> OCe rkd gap'n y.Xchv furennc�d
<br /> a Ce"IrW copy to fled-dlh the enrlmnf rcos Hcalth❑pv r l
<br /> CSRTMCATE OF EXEMPTION FROM%1DRKER.S'COMPE`FSATTOX INSURANCE
<br /> C�]d4]SfIPpW°'�d.Q�LCss'C'a"CR��'11LdICPS2nlS IS.CY„Arrr..IPIr�IPt�dllinl�t'�.nLPL�4.3
<br /> I goofy Uwt inehe ptrfO+mallce afow work fat-high thn pend9 u iasrued.O sbaG our romlOS any pmson m.any en amce as as to
<br /> bx.subject%rhe Wmlps'Cpmpan m Iawt of c tllOraw
<br /> D.pn• AVptdnnl _ _.._ _.
<br /> NOTICE 1'0 APPLICANT [C, aC!m mvdog dris Cemfwrtc o4 faelc+naw yrt abvrdd become svh`.I on the Wmkm'
<br /> Catlycnmti'lnpmainw'.aMehe Saber Cada.yuw+mst Tordmilh compW u»h suhpemishxo mtha pamll rtvll be deaoed re.'oked.
<br /> C0KSTRUC'1'ION LLKDING AGENCY
<br /> I hueby vm m"I them e.n tnrxnuealrn.Ierldnng corny for the pmfomsa¢e of!bc work Cm whah Ihia prnel it Ltrurd(SeOU.
<br /> W..(,'is$Cwb)
<br /> DIVISION OF rNOCSrRIAL S,AVETY rC UCT CUITICATION
<br /> O I hmcby Cit(y dart m caeavativo li c(S)w Irmo roe;m deplb Imo wb,ch a perw'u segwlrcd m de lnnd,wilt be made m
<br /> Kftuecmao wkh uvk n+lhwiecsV bg lhu prnmrt,aml that ea bmlding aton,=n,watMing.folu o,k,Or drlm hams on,dUvunLbop
<br /> thereof,-till h We dun 060 -ria ILEI 1'<n hill, irlwpler 3.+.,Or.rap 3,Ao,.Ic 3,%o non 541,Tmly h.C.14enriv Adgznl9lr!eve
<br /> Cad.p.
<br /> C An as. lnuuAm I wA mut errplOy anyone le de arm'wI.a would+-qurse a permit I'M the D"..Of Irdratrul Sodm•.as
<br /> meed r1w'vc.minrsub Perron byn nn"I w ub rob umk from me dreisioa.
<br /> — O Dh own Oe dl,F feral Sally'Itnns�_
<br /> 1 •emly lie:I have real Ihlr appLFal1'nT all rale Ihrt the above mfomuuan m carrcm.t agree to '-tib-ll my and county•
<br /> ord'mvmer rrd smoebws nN:L�m well cgraee=tion urJl rrr s<wegr syshrntonsbuul+uw OrW had+y aallwnsr ryrtsnlru:ires nfrhrt
<br /> cowdy w ca"upon the abo%v-=naltmrd pmpert)for IeapecRna pnrp9res
<br /> Dam App W49
<br /> L'HaaN`� Anan}N'd'!Mf'Fr:I N.rJel'.z^tilbala:atili.q
<br /> I!/4Ya:
<br /> ''/2011
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