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.rOI ADDrtr� �Z-17.1 t'�D_llw�4.�.�lfsh 'f'r PtnnAT 1N�_
<br /> LICENSED CONTRACTORS DECLARATION
<br /> uo.Awl
<br /> f.lnm.N I'm Ilunxd undw rhe pn�uion'ofCFaplw 9(formleahy a9th 95d1m 9Joa'ofDivYir3oe Mebx,m.rdprofex
<br /> fes11 foes W a rc � irKoe.xe ny teex a
<br /> LicenseN 942-2 EspintloP Oen lZ•- Oj
<br /> Aap l0 11 Cantr,eeor_ LKQ�o•'A.`f(n.�'-�Slr�i d[sr.hc .�
<br /> OWNER-BUILDER DECLARATION
<br /> IMnbv aRmt A r em uelro!From rhe Conv)eror'e Lima I,ev fur Ya Sol kiwi.,rent ISM.no 15,Statues ,d PrtMtldu Cod, IW ub�of w w,
<br /> durroea P.mdlr ruuot if". arpnv.,dwnohah,or nryr any rhrxnru.mor ada ixrafe,aa'rigors the cpplxenr Air axh ' r�
<br /> he eheed)d pun (0tho'wieiare,Otte Cwv.."Lnvxu La(C,aagx p;uoxMwdia rdA Porn"mflh.dpiud earo,rCedd)
<br /> yds he in e[err9�(•'hrmhonudlhe bn:.for d.al 4ahawrt 6 n•�ion'n00)ofOrurtla,l orde Pveirx erd l°rok.uena Ctdel
<br /> Win eon llJe i,,wLrd.}al:un(afOn)). pr M' �"Y"o ofledion 1p}I.}yy xrp ep)liemrfweparxil.ubjaoa rh.rphrm ro.d.n germy
<br /> D h o me.of ti rrapry.s n.Y a"mpigea,wNh e�eyr u(heir sol.umpery.tlan,mail!Oft wwk,wul
<br /> 9v.irh"abw:mn o ern,Metas m orarod rot-it-1n'u:ion'/W',
<br /> W y n Code:TFe ir 'Lwmu Lt.dune na.epply to N—W'�of ii pdeM who but Ido Or iwown rh.m.,and who lose ew,wore hin.,f ur
<br /> NnwyF Ne ow PI:/ex.Prdv&4 shat rush enprovmm-nc rift hutted or daaroe for We
<br /> mxpinr,d+P fwlder mall Lama dt burden of nu ho did nn Budd x i e It lawner.rhelrtlarnaairnwY.mmunld.'dmM oesr r.x or
<br /> i P'o"'na '^Prov fades vvrPoxofrl.r
<br /> owner.f the property,stn eselupiveiy cordnaing with lice mud conducting ro ceras}Ict the project(Semon N:44,b,ddewa and
<br /> .off ostr Coe(BkPC) Tilts CotMector's License Irv,doer ria apply to ur owner of property uhn bunds or insprovna hreon,end
<br /> who dpnphucta r such pr pile's Witt a=UWWr(s)iicanted pineumt to she Coramaotor's License Law.)
<br /> ❑1 am exempt 6WO Section , JWC.fir this trepan _
<br /> Dote:
<br /> Owner
<br /> WORKERS"COMPENSATION DECLARATION
<br /> Cdaooki))
<br /> ttai Thew'"on"eof ooweuit xY:rwu Or'"'rest'rest afW'r 'Comprn :navnnra,vaoertiRd Dopy dnnof(Jeoean)4%,Libor
<br /> ) I
<br /> Expvatloss Date
<br /> ��{j�c� Company �j`�s�'G Fkn�
<br /> Q Certified cols I is heresy hinnished
<br /> XC-"ed copy it filed with the Environmental Health Department
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURA.NC.E
<br /> C.li/urAa
<br /> Cartpautiep
<br /> toonbdude,[yes,}inpafarauu a'ln trots/erwi,ieh rhi)rrn:l ie iuusd,l/Wl rorarpiyuy period In My nawbrwrc wh
<br /> i w he ro Miter to ra wanes'
<br /> 1l
<br /> Date: Applicant
<br /> NOTICE TO RLICANT;If nice making this Ceetifiea;e of�cceyloay you should become subject W the Warkonr C)mpennatim
<br /> pmvlsims of tx abor Cede,you must fafthwishoomply with such Pmvislom or this pmnitaball be deemed mvoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> Sn.xby affrrx Out drbe is.mmsdxrthe"'n.ecymee perfyrnw'-fu-"*for whhhh,lis"it is..it(Soft.maws,nisi,code).
<br /> LenAer'e Name
<br /> Lender'Addmal
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> D s"wiby".aiheh.�ria.aeewdr aw(d)w more Ss ie Gph io.oti.h a per.y rr'rixd to drrrd,will he mode M wrrr„w,w rmwai,b the
<br /> perrne'Mda.r be1dYrp fruuarn,eaHddirrp foul"",Or d6nolAtoll Or diornana tenet,.11 be,a,h,mr it"41k her roslr(G1upM)3,awP-,ARwh
<br /> Bclir)al,7tde I,lCalifrMa Adwinur tiv.Codel,
<br /> Cl As ouru-bui l will not employ anyone to dP work which would require a permit from the Divefun of Inchim V to]Satary.as noted
<br /> above.Jnkxs sacl IIperwn had a permm Id
<br /> it o such work from the division.
<br /> 1]Division of Lndgptral Safety Permit a
<br /> IeerWyaa.r[Nv reed thie.PNltAn'e"nd nue rbnthe.a.vele(nresta.buewxll�rr<r rnxpH vita ap"yyfy eu.y'rdMaw'and axe hwa
<br /> wraaYrwMleme sur'Mweewee'yandr eenaenr,Wr,end lre.ebywharir rrprrr,gp.a efsG"r,ryrux"epe fa..bowq'ntiorrd ProP'rty
<br /> � ib lerecthe guest's
<br /> Date-- Applicant
<br /> Wm a.ta.om
<br /> ew:oos �wnw Ce.o.ewe +..I.rmienex
<br /> Z0 39Vd -i-ivood 33n68 STE89SC80P 50:TT b00z!11/01
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