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LICENSED CONTRACTORS DECLARATION <br />rdf6ssions Code and my ficense is in full force and efrecL 5(cOMMencing vAM Section 111 DiwWon 3 of the Buskiess and <br />leense <br />�4 Expiration Date <br />OWNER-BUILAER DECLARATION <br />,.«• .I. <br />as <br />Pea civil nalty <br />Um <br />five hundred dollars11 1 _ - nra - _ <br />■ with = sole com <br />Expiration Date <br />Company. <br />CERTIFICATE OF EXEMPTION FRONT WORKERS' COMPENSATION INSURANCE <br />� if, after maldril; this Certificate of <br />ON LENDING AGENCY <br />DIVISION OF INDUSTRIAL SAFETY PER■StT CERTIFICATION <br />.• _ rl • t . 1 .. r s• . t - •• 1 .' ., • 1/ i , t «(1 ' Y, '1 1, 1 , h - / / ,1 - .1 I/ 1 ,1 4 <br />Til 1 <br />wouio require a permit ftm the Division of Industrial Safety, as noted <br />abovei unless such Person has a permit to do such work from the dinriskin, <br />certify Mat I hme read this application and state that Hie above informahm is correcL I agree ID comply wFth all cdy and county <br />wilinan Aces and slate laws retailing to well construction and or COnSUIA ITTIT aTie rf,=pilot n �• _ <br />- ••:.. r, <br />L <br />�t�a3-az-oo7 uc�s®corarwlciaRs or�utannoN <br />rr� <br />