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06f1.8/01 15:45 FAX Q ti2 <br /> San Joen CountyEttv,::rrrtaj�ta# He�itfl Seiaices, ':Jn" IvV1 eli i5ermit Appfic2rlo t 5, upplemenr <br /> JOB ADDRESS <br /> i <br /> LICENSED 17,0NTfZACT0FRS DECLAF 'T ON QCQ) <br /> '2 r1,7 .`Ra: i Cr WO =Y sn—s Of Clapwr 9 jcarr;r-n9nctA 'rti-II(1 'r-.. ;i, fir• r <br /> `? Ke Eu r_sa aw "M. =1 Woe :1r;--'•��'. Acense IS-n fuV arc=are gHeat <br /> i i-�ans2 - <br /> W'73PZ• ER-9' (�OMPF-NSATtt;SN DECLARATION <br /> r e_ C'3:r �C: �,.`a - .'r .'�= _� t-`�''c,l}C•'Nii'.:� �C'�:3,•'cvL:^/;g' fcHECK A1.1. THAT APPLY: ' <br /> 1 ';3�F.� a'r_ .'.,f .-.a+.•-� !:'. . r_:J ti .^,'--'yi,Sr�f.;.it,'�.S I._.: �til;m �r�r '.`i�:k:FC.S :•� G$R�s.:v-.. zs wro''i'jed Li_' <br /> .. <br /> RAnzar 7701 <br /> a- :me L__.., Cc de � t?Y Q,_."'F•'_`rC'.�'1Ct'r -. w ,t:,.'f. ,:r :rtrr,;GR LCIS �m.Y:l: i� l5t-:7d. <br /> .''ion Tia:,,-.- r ,'" moi;' ;3i Cf. �i�L'!'3Y1t:&. as .eqn ea CY sector 37CO of me %y ncr Cc:v. <br /> + i5 . Jec, r;iY:'7=+'1i�:r;RV,f� v^a� oyr9t� teL�a$-Is <br /> ; <br /> a ;sirenny _� ?wLgcL •T;~tv^:'kers, „icrrpsranon iaws or <br /> SAM: . __, n n - ._ <br /> .. •• y,.ti•'.r�,r�' `., -.,is rleo'I!i" Li�:•J:5 � W SR:':;C,^, �1':�' .. t ,-�.rr i• 3!'9j: <br /> WARNING. '-.�.:1 Fi€ 'r 3e'� .n^� '+'�+i+�f*$.4'$'(J[7:T?cii$A7?t 1Cd COVERACM!S I1HL.%vVFUL. AND 5t?AiL SUSjE CT <br /> AN EWF*L�''=� +� Gr�:Lt!`::L 5�:' T!�5 :{1CiiGIVIL'IN E <br /> S UP TO ONE MUNoKo 'PH04iSANC QcI-ws 'L'� <br /> S"Gv7,OCo.0 iJA^iSf :G T.� "?I# �' ,ti "k }`N-'ATICN1 1NIT <br /> ti CQSTE',� c ~' <br /> fi +� 7, Ai'i Ofi'fdl"' 'EF9,rtifl^ DANACsf=S , <br /> bR CCS <br /> — ........ C-Se Ilcwt gefl flU4hor xb� rx�rr�5 rrativrj, ;';c+ ¢r <br /> �Utl=ar;2e' . <br /> :W son Wo Sar, Maqu" ,:"':'o-M.•,,. ANN pt;r'Md ApOcabon an my. afiait. i undornwid this auCh�rrxaCsUn,s v3i�d r.r <br /> ww- is '•-c•.0vu..-r. poll Qviv- va thyipgpt p <br /> .-°-- - .. -.--�-- .� �. __ 2r4 of this 2i:µ1:CSLorr, <br /> VC abed `.9004 L0-64-unr 'ZOSO E4S 5Z6 .` '3ul `6uT:Vsel V 6urtTzu❑ 668,4) :Aq qua <br />