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12/l0/98 16:47 FAL 2e3--_'-,225 MrlES7U ATC PAGE 01 <br /> 3 <br /> . i Aht k, <br /> IiN.hraqulnCou <br /> �b&ni. t s c W v�"�'L✓�N 1Vleil er+�rtit/`pPtkalOn# of <br /> �lows � .roa ADDRESS: �,� � wa PERMrT lI*P-. C2Z <br /> LICENSED CONTRACTORS DECLARATION JLCQj . <br /> i <br /> 1 hereby 801 that I OM Ike,'raaad sender flee pr vioni of Chapter Q feemrnwmin0 wide Section 7000)of Olv+sicn <br /> 3 of the lOwww""Pr olm4ns Gude and my license is in Tull force and*%CL <br /> Lianie t Expira600 <br /> Doe: / <br /> IIs(IrlNili�l; TIM. ) / - <br /> inflated name:ll� ..L.. V. <br /> ` KERS'COMPIEMATiOH DEOWMATION''--" <br /> 1 h*Mby affirm U'Idw W40Y of 14+1rY One of Wo lictiowlnp dotl&*bom- rCW-CK ALL THAT AIRY) <br /> i r have am wit rnalnta4m a certnkats of coneerrt io eetf•irieure fbr wodcars'oompvnmotion, as pravlded tear oy <br /> Seaton 3701 V tare Lsbw Coda, for the pedorrnanoe at Ive wont br which this permit is i"ged. <br /> i <br /> I"INVO era wit rlrltntVM workers' compenaallon Insti, lCe,as reaulma by Somon 3700 of the 600 r Coesa. <br /> *or the porlbm+enca of the work for white the perrrrit is issued. My worhefs'Cornpensesbn 4nsuran:"e <br /> i gene.-acrd policy numb" ate; <br /> i t <br /> Carder. Panaytimber. <br /> ._..k cert:VW to tO perfbrmaeee pf the woes for w),kh Na permit is Issued. I dies not orrip"any} penes in <br /> i any"W10AW e0 AS to beeonw U"Ict as I«e worfrar,t'WMP&A400rt 4rws otcalftmin.ar%d agree that If I <br /> should tfec&m fubim w tree workers'empensotk)n proutsions at Season 3700 of ow L gbW COae,i eh*0 <br /> t nttwith comply**fhM prvvisi4 t <br /> Gale: 11�Ie19� w_�tyinatare•, <br /> Printed Nlim�' <br /> i <br /> WARNIMG'FAILUM TO t 1111CU a W01[#(4 e'CaOWD(@ATICFI COVIRAM to LNUAWFUL,AND SHALL SUBJl R <br /> AN 2UPLOY110 TO COUN14AL PV-NAjLTL6ti Ake crtaj.wV409 Up To GN16iLUMl1l WD aA%Vo t o"AR S <br /> i X100,400.}, IN A00nVOTO TH9 CWT OF CQVPZNGAT Cft INTERla'rr A?T0/WEY•8 MA AND DAMAGMS An <br /> PRO00*9 FOR IN sI nom Sim OF THE LAD011 CW6. <br /> (C•017 titelgod mutherlaed repewer::sUve) ++arebtr <br /> i authe <br /> b$40 tlrte UP Jaigxln CGueAr 9VM1 f+aweq Appkgst4m on m$y balsa::. 1 undemland 0%1%aVL%*Av~I6 veli!isr � <br /> i sne 41 ser sold b krhitrd Lo the WM. n dated an rhe Nantof Iris ars+Psesstonr <br /> 1 <br /> • <br /> �t rlg, SKTH <br /> M1�11:a„ <br />