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I iry i-UJ -GtrvJG 1H•JG rrl.Vi'i rKCI,1 1 Vlv JI-n'Ir"L 1 I"1U i u r.vJG <br /> 82/19121)82 16_12 2894683ti�3 FIFTH FMOR PACE 83 <br /> Sm 4Gmqutn County E"WMM>Hps*rftl F1eaM DepwtmerA U.-M!b Weft pm-;d r449icanw,S::s erA <br /> .JOB ADDRM: � s.. L,\e\t S;�T _�;1;�-L-,PERM <br /> LICENSED CONTRACTORS DECLARATION <br /> f her byaor lug[$m iberMW urVW lft plosWOM of Chaptw 9(wrurwidng viM secfon 7000 of Dwoimf <br /> 3 of VW&Akwz and Profen L ode WW n►y lcere$@ is h td fake SW stied. <br /> mss: 634'.--3-Pssoak-_1/—Z, )0�z <br /> Date: 1323 L Com: /e..t-"'S �'oh 'q / ti <br /> VVOPJMW 00049JSATIOK DECLARA110N <br /> I teary+of yn vrxW pmnW of peq ry one off*fairwbv duchwafimr (r—CK ALL THAT APPLY) <br /> _ Chair and a�sir►oeYti a oar$1aAbe cf noeW to seg4nvae for workwe aorrpWmo Son,aspic ids forby ::: <br /> 37M e ft;L=W Com.fa:Ire pesfacnwn to of the*ork far which Ws panvi is issuob <br /> i hent wW wit nsakAWn workers't%mm mat ars insurarvm.as requlced by 3tc- 37'o arsim Lagar Gbde, <br /> for fie pmf mpflCe of 00 wm%tar Wf ich I)b permit is bmied. My nrofi+om omrWor okn . <br /> oemim end lett am <br /> c,,,;er r �it,t �./ :i►frw�t,..: (.J c► 71 6 3 g o r <br /> _1 cffft IW In the Pwlvnrnanoe Of"work for«obich this pom*is ,t+sem rml emipioyr any p mun in <br /> "MWWW==1--lAcrJrnM 63;2W wo(XCW mon laws of CaMomia.mW aero Supt I 1 <br /> shoM bwo 3 e w*jest b the wm%eW omVwmytion MvAskas of Sects 37W o1 ins Ubw Code,100 <br /> fortram cavi"y w1h Bose p mvk1orm, <br /> poh NOW ffs 4yv-r_ <br /> waw FMUM 7"OS"UM WMMMW rAii *WAnM COMA"ill UMA*w s,ALIp MftL BlJiL=r <br /> M at W?M To trdMn P"MTm AM Cn hoes%W T.,Q=M SAMM TWOU"MD OOL1IlRs <br /> RI=oM.L w AUftn )N M"M COST of l itTlDll:WTMST,A j g f MO M AKAGW AS <br /> MMM FM M ffiC?1f]It 37f6 OF TW L AGUMM COOS. <br /> L• aiG$7 tic�oaed�rormeCt+ , <br /> basLry►aewerlsse WWnepw r- c a vvt S <br /> ea sip tL;s Serf iasgofr►CoyalVr S1�!Narafh APyip/oa oe o�bofiifL i wcder T1s molu ingot iosad for <br /> ow('i]rw snd is IiesLfoed Mtn*iw k plan ftkd oa*&f "~of"appieatfm <br /> 1�82lfi <br /> TOTAL P.02 <br />