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I <br /> '�'In+t+�ttvirt'Ctxzn't+r .. _ ... i#�IEart1't�saT'ttilent <br /> WELL & 60RM G i'ERMff APPLWCATION bUPPLEWIENTAL <br /> JOR Ai MESS. a-a Ll PPPR "Wp 9 _ <br /> L ICER SED CCONTRACTORS DEr'LARKT ION <br /> I hamb'y affirm treat i am*,ansmr unber thn G Vmions of Chapter 19 tcornmen6nrq vft Smt,on 7i..)W)at <br /> Uivism 3 o €cue Ca-IfOmia business and Protessiorls C:oae ana my zcense 6 to O0 Some ana ertea. <br /> i..onifdclor iiarne. 4r LAV'a <br /> �2R !^ f)c?.'� <br /> I a�1(71l"ditYll:_ � Y 118F:. 1''f�S00e0i0 <br /> Print Name: Kat+,R 5fto+tt^_ IDa+s:' verst 9,2^„ <br /> WORKERS' COMPENSATION DECLARATION <br /> of <br /> � L: ^r'��,i..-J r.' `' ��_ .�."' �..: �� _ ...ctC_y'.�.`?'�'�. �� .�.. (�/1•�'Ll"' _ �:.� -'r t' _ a i._f ",'�i�" .f7t;� <br /> /lPff�fr IC 1CC!)�. <br /> frw the;RTf'V s*ar,--r&!he.%mxk ,rys a,!. i•;K s:rrl. '��y*�:�rk��. <br /> comoensator carrisr and nof'cv a-a <br /> C.a"iier: Staieiuna a wkw <W ry2fjro a <br /> •^.^M77 <br /> ?4..- <br /> j Cirtnn4iJrF+' , <br /> yo i w <br /> WAR�NitiG_ FAILURE TO SECURE WORKERS' " PENSAT(ON COVERAGE IS ZI�LLi�{ElF(Jl AND SHALL <br /> SUBJECT AN tEMf,P` 0YER TO CRW.,NAL P<E Mi-'RES AND CT-ViL 'FMES UP TO Sloe.m1 im <br /> Aaai1►L't1 iiaYE ESt, Ai! 4* ki ,ti:t'S SEE'i,, AmD L?FiWAGEG <br /> A M4nQ;7 ja►fFni7 nTHFR THAN i';-57 qIC. lMry PFPMIT APPi ICATION <br /> 1 ,t�eceoy authoc�zeS <br /> 1^.Z 547 , -ok- _ .-';I P s+1i 'attic authorizatio+ti is valid fay one r fl? t to the work 1pn da an front toaae of this.aanlie,�tivrti. <br /> END 29-01 6-1-2017 'NNU$nnm P---m I',r4°!ca. <br />