|
Page 43 of 51
<br /> ype,Iggpg�; 23537 5., FREDFRICR __ pgtgplp Y:
<br /> W,pori -
<br /> UMNRED CONTRACTORS DECLARATION
<br /> I hereby Aff=rn 1M1 l am Ui.d uratic ttr pavksim=vfQ.pee 9lcaemvettrirtg wish Sedan'WAI ofDwIsian 3nr[be sw ut
<br /> a:d Professtaes Code and my Ureeve is m Cull fmcc.ed eRoct
<br /> Lkcmeu 244813E11drallom Dula_WtY 31y__206d
<br /> role 1-03.64 _- Conuwt HERMURS 8RO5. GRIL_ [tS CO r_t—� 5�.•— _
<br /> OM1YNE,R-11UILDER DVC LARATION
<br /> I hereby AM=iha, I am eaeenlx Gam Ite Cmwaeror't Woele, Uaw fur Me fndmwumS rNsam fSecmom'93]< Ruuoess and
<br /> Pmkgaem Code: Anti ntv or termly which mqu=m n pemdl to teat=!,alter,imprrnr.drmobfn.or rep any sIrucmme.Pour to
<br /> iia issuance,also rrgubde du appk:ae,fm such pdrrmt Ia file a Stitt ribRoacref dot hem licesuerl pmrsulm la&-pmvtsimfa of Ili
<br /> Cmvmemr i
<br /> Lk .[Aw(Chapter 9 tcatr=neocmg with Se:eam +w)of utnisiom 3 of We ad oer.sand Poofeaatoos Code)or Iha he
<br /> is eseuqu bxftmrc and.'the bmis for eke alleged eecmptom. Any vjeW..of Sclfum 703[c by ov;:apple.!:fm a pervtit srtbj,-
<br /> Ibc Aplpiicam w a cm•I peanintsr rat mea than fur hundred do:lms(S3nd)):
<br /> D 1,as awner of the peop.rty,or my er ploys¢.,Th w48ra as Aheu u ie wi pcmauon,well dm the wc•it and the mruerme is au
<br /> imend:4 or oRerpl for sak(Sxtioe 7W4,@wnass and Pro inions CqK The cnalrgcuc's Lceose Law 4y oat apply to an mww
<br /> of pmpany obp builds ns .Vrv,=;Genn-�,and Mita Wco such wank NrI mlf et ihoaugk Ns own emi ayees,lxtyeidad MAI s 11
<br /> 'heQ a-bu am nut m:.adee bu u[Tmml Far me. 4f. d-J mc.,elle building ov n6ir themrnr,t of
<br /> k,I ant year of comp]e2aa
<br /> _ the axxrbuibkr wall hurt the hLrddn of omvwRf1191lInd:d eathuld arimpcslvr fitr ase 9eAfau ofgle.l
<br /> D 1,at vw r of'be Propeny,au:exalwntly_vmrxtlop wtdt Lmnud comirarmws w eums=a Or prujnv lSemor 7044.Ilmi=cu
<br /> and Prafgrs6inu Csde fOdtlM'I 73a['unmaac;'z Lmerx law does eat cpplymum uw».;odprmpmysMnkmlkk nr impm+i�s hewn ,
<br /> atW arm co,nttuc=im aucF,prtyner wiA a cunteaemKlJ b:tacd pmuagtlo die C9nrfa:do,•'s 44tns Law.1
<br /> alceup[mo -semmr.
<br /> Darty d DWPM —
<br /> R'ORKERC'C."PENSATION DF.Cl-ARA'IION
<br /> Copy Ehy cfflYlheaioc[h3a8v9e1a,Lab.Cade ro?f.rnnur4 to u W insure m a cert0eac of Warims'Cutrqum:ata!lramCarme.or a cr;nfrcd
<br /> E,,&'dov Dam 1-6.05 — compamy STATE FOND COMPIeNSAlION T".
<br /> O OmAkd+opy n 6mby IL•mhbwl �I
<br /> WIP1111b dc9py k,fiber wilt tike 7:nvtmnnrnmt Rrallb Deparer o'.
<br /> CERTIFICATE OF EXEMPTION VitOM W'ORKE&V('d)NPENSAIION INSCRANCR
<br /> flYyu arHrca onto 1Lm,4CS=lr(CjLt7lrggmit nSP_ene F.•.endted dolGn f�'er1,, jpey
<br /> I cv 0Iha m ole yerfarrv:ms o:LW work 61r whxt thll perreo,if etAmd,11ke11 oat cmplay amy"two m am'!Duma 10 as Io
<br /> tee.cubjw to rhe Wnekerx'(:unkt+svatrnn 1>-m afCalifcssa.
<br /> DaAt•, _. Applkaea
<br /> -II NOTICE TO APPLICANT: If, aitr mrkiTig Ibis Cerdf ate of E•icWbon, wu ilrmda htrnoe: sm5ject to dsc Wakens'
<br /> CAapensauon peavmioa of the Lobi C=dr.you mim fitdhwah tonply wick sorb paovninm or tbn pmnet shag k d...:1 mvnted. `
<br /> CONMTRGCCIOY L&NDLNG AGENCY
<br /> SII IMrebyAtIr.,balne oacmnnntion rcedingopw'e tar rhe performance of tltrwmirn.which din pceadt miswalfSelwo
<br /> 3097,Chi]Cade}.
<br /> Linder'.Nava
<br /> J Lmdal'Add.
<br /> i
<br /> DIVIRON OF 11"USFRIAL SAFETY PER\RP CER'TICAFtON
<br /> O 1 touchy cetify that as eatavaalon five I y]w=tare Ice,it depth mm which a pmon:t.,Pored m dtact I&w:11 W made in
<br /> <vmccfi.wnt wml authmimd by OB pemtir,aid trot ea hmlldtgd samnwr,wffo16ng, bbe rk,of derrmldmn it,di oWulmo
<br /> dovwi w111 Iw Itrw noon Iinrg.ai,r 63t)feet high 1C-Fla 32,Group:.Mick J,Svcmn 341,':Wc S_C'nhfomta AdLLtientedve
<br /> code?
<br /> O As tweter-bu.t!er,1—At nor onpiny do cork-.Roth-.eM rrqune a ..a fmm rbc Dimmam of rod o,,'41 Sefen•.ss
<br /> ormd abovr,unless swh pcsan Nt,a peanut o ti quell work fleet the tGnsian.
<br /> D D.,o t wrNdmgrzl Sorely Ikvty n
<br /> [ceeeu+ this 1 Irsse mad IN,applvao.tn and,gate aha rine..v tO." ram et emr t,r I.gree to Imply w+th all sty ono.outxy
<br /> aedsnanCes amt uam IAw4seatr:y{m 1,0 eomerumm.and or aewage.yuem c.metmcnon,and he e4y a=thornx ryresenraetseq.1 lim
<br /> cottrdY Ineam upon the ahoa'e memtionoi pmpeny for r,pccwh prrpases.
<br /> Date AppXet}vl
<br /> kHn r}-0e.OYe lAn.it u•n'sv-tar-rram:s'.+erwr tvc:cscu,w
<br /> /2011
<br />
|