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06/28/99 16:26 FAX �02 <br /> h1J KLUbtllj!XVNG PAGE 3 <br /> R <br /> 1 <br /> L- Lie. <br /> PERMIT#:J0S ALDRESS: � � .-...i r <br /> t. k <br /> LICENSED CONTRACTORS E)ECL.ARATiON f <br /> ' I hereby affirm that! SM licensed �underthe MVISians of Gtsapte'3".ccmr'4!v-M9 wi70". SeC�Or 7000 Of Uvisi0� <br /> 3 t?f itte $ustrtess and Professlcn3 Code. arra rnf tinertg is in it borce and Affect. ! <br /> 0 i <br /> $Xptration Dale ; <br /> r <br /> 1)at@ � 1 e 1 �OC(t:'2iG:CrWORKERS' tCoMFENSAnoN DEGLARATIQN <br /> i i ttertevy affirm,fiat! haw a certit"tr,.,ate at Const to velf"cure. or a G?r't'fiGste of 1tVorktarsCompenaPit►on <br /> t�aucB�Ce. or a 06gj fed copy thereof{Sec. 3$J0. Lab•C;. i <br /> EXP. Date �✓<_� Cnmcany <br /> s tterex? <br /> p Ccrtiftad Copy : Y furnished <br /> �Gef ifreQ X04' is 9fed with !pe rovnty auddir+g irt5pei 0��»r� <br /> CIERTYICATE OF <br /> EXEMpT14N pROfd1 WORKERS, GtMPENSATION INSURAhiC� <br /> } 'leez not 09 <br /> erti fy� at in�ie��r'�ar+Ce o!?�e want�;_�mis permit+sr g1t;W, ii shat�ot emgioY anY Pmrsen n+8ny man7er su <br /> i as>c oe ome sue ro the wortiers' Comaensatior. .Awa a"Caaiaretia. <br /> ifete <br /> i I ' tef � pcio <br /> tQ <br /> NC"CB 0 AP�AN � dvisws nrth s Permit s� <br /> ;onperivOtion Rr• ru ans 4f Labor ad+w y ust�ar thevs �y wih sue + t <br /> I <br /> pe oaerned revoked. <br />