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66 -EI t l C7I��9 i OV& 0 1 Z I H1�ON <br />Feb 2 <br />d'5S 5ZE66£''9£ Q �,6 � <br />O <br />VbSNnoen ra 1onjNiyP g. <br />3Z ' b <br />;371S I�IAN33S <br />d s ery zr ansaaois dpi Nvid ills ivn1d3:)N00 <br />0. 4 (AINO N30Y%N) 13NISVO .SZ X Z <br />•9'.E WIN <br />F10EN'S*r:D CONTRI��LNL/I I6I�1 d�BX pONI151X3 =1 <br />fiV4j17 7 I M t1NJlS <br />I hereby affirm that l am 5 ensed�,rn�pr p�pVt ionybf`Ctiap fti�nCinfl wiM Section 7000) bt 000von <br />id nry <br />r� fi • i Q – – _..., .. �. full – <br />f <br />-EX0 "tiante: i <br />Date: <br />Siortatum: I - T": <br />Printed name: <br />1f CQ� n TION <br />I hwe-by affirm under p o fUi talions: IC APPLY) <br />_ I flava and w10 am 'n Is sent to f-Asure for wp , n, as provided for by <br />Section 3700 the n work It is issued, <br />1 have and will. gain 'n workers' nsu nCa as u" by n 3700 of the Labor Code, <br />for" parlor tho wrorlc kr lh f(f it is' sued. 0ornpen"tion insurance <br />carriw and p0 u <br />Carrier_ I Policy u r.T <br />r � <br />_ % Dertly th* in fila performa, o work for is lzed, I shad not empby any person in <br />any manner so ��p— p to thu leers of Caiifomie, and tigree that if I <br />should become to 00tH p 1 S of Section 3700 of the Labor Code, 1 shall <br />forthwim comp wrth those i3iOrts. C> <br />Oate: Sign <br />Printed l5 <br />WARMNG: FAILURE O SECURE C ENiSATION COVERAGE IS UNLAWFUL, AND SHALL 8UBJECT ! <br />AN EMPLOYER TO t. Q L FINES UP YO ONE HUNDRED THOUSAND DOLLAR" <br />(9100,000.), IN AMTJ THE 7 C SATFON. INTEREST, ATTORNEY'S FEE,a, AND DAMAGES AS <br />7RCMDED FOR IN 8 11137% TKA OR CODE- <br />I. (C-67 Mten"d au*wizsd roptasermrave). Ngrrrby <br />to slyn !iris Sans I in VNrMt Apokation on my behalf- i un**rsund tM authorlratkm is vslid for <br />Ona t artd iMd m tla:leC on tete trent of v►ta iCatiort. <br />9/V abed`061#–yffJMV[AJd6Z:1v 00/i;0/ZO `•980L 4E9 Fog 066n X?-�;af :Aq �ua5 <br />