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9256856768 -� NP LraserJet 3100; 1 2
<br /> Rece.1ved: 26/11 /07 15:00; HULTGREN-TILLIS E' PAGE 02
<br /> 11/28/2007 13:25 9256856
<br /> 3OuAnnays9, _t ii DAD W. � q Cvf carIa - Qr��rtatilrra: _
<br /> LICENSED CONTRACTORS DECLARATION
<br /> I harcb'sl mi lhor I Am Ik.Ckted udder 11.orilitki r,vffllaptcr 9(cuinnienaiap wiih amide 7(Io0)oC Olvision)o(thc lusfr,Wa and('rol'emaiupv Cii and Illy bctdu Ie
<br /> in 11.11 frets mid chat- r / j�
<br /> I,lsrnac# � Expltotlnnnett If /��r "
<br /> Dale 11/2 w1ti Contrec., T 6,e.-- evn 5K 1 )6) s_
<br /> OWNER-BUILDER DECLARATION
<br /> hereby sllitnl thai l Mtn o—int iimA'ht(;nNrndnr'y,I.Imok I..w tiro Iha IfITlnwlhy iwx (.Stttinn 703 L$,IleaineM:mf fln,rcglklln Cede: Aey cry W en-Iy whleh
<br /> rcyulro.A lW/nVit to Carrion?",Altar.impinve,demoun.nr.epav ally 1rfln, M,morto iv iWlance,alar.rsglli 4texppl.c ml IIOY i plllilh 10 fill a■(yr.Wll'wlernc ll I11a1
<br /> M i.'ptosed pv!Irant In Il.(mAvlahv,.nrncc Fnmrncnda(.Itcu.o I_sw t('hnnlarV(ettmnunolnj will Stolon 7W]of nhi.im 1 of tho Ili end vrnfcaslun,(-.ndc)
<br /> m'theu ht tsexemrd hemfrum mrd the haala)'Ar the aniii arcm(dlna,My601n6",of 9tclron 7031.5 by ai•,y.ppllcani.kl a r ri nioiaett the oQ),1kanl b a civil pAnally
<br /> d"m nxiru dlwi five Iwotirled chitlnn(xsno)y
<br /> 0 t rt nwnor oflho prnFWty.or Int'pnployum wNh vo�en�..trot,Anal nom?ensu,+m,wif J„(hu—6.W Ills alnKAvm in nal Init i(i tili fm Alto(§4117(144,
<br /> Ii and rMkinloaa Colk•:The cnntrxlor>L1 ii I.nw does oa..lpply In>n alraer Of y.ylmy wlw Ii.0 illy.,m ,,thYAnn.alld who dro9 such w,Il;hlrr»rlf or
<br /> Ihmlph In.1—emqi pnrv(detl iMt each in>rnn•rn..nn ars nor IMrndod or nii fn,-.ata. if,hct tlror,rke bnk,uny m hIVII i'll.is told Mflim Ano year nr
<br /> e,hirel irr.t(ho owner-h,dlckr will h.vG thpb.ri of pinyina Ihat no did not ba(IdfY Ilnpre`c For The parpwc ofsnlcO
<br /> 0 1.os owocr of the property,orn sxcla ivsly tmnttnoting with licensed contractors to corle(roct Ills project l,Seci 7044,Hosinays and
<br /> Prvfcssions Cole(B&.PC: Ibo Contractor's Liceme Law docs not apply to an owner of properly who builds or imprvvta herli VW
<br /> wllo eonotrucii for such p)njccta with a cnptrocu+r(s)IiccoFed piontiant to the Contractor's Lji Li
<br /> 0 l am exolupt undef 5echen DliafC for this reseon,
<br /> Aatc: Owner
<br /> WORKERS' COMPENSATION DECLARAITON
<br /> l hcletiy wliml lm„!hovil o rrrrif,care of oonveln i„wlf•inwit,or n csnil)tme tlf worgen'CMlpcnp Inn lnsxrm rci:.or,a tiFpd c4pY lncrtvi r9eulnn)400,1.tar
<br /> O �/O 1 ld s Csaf•rtet54k Yi00% 114 S at►vt ItG� �t
<br /> ExP1rYtlon Da.te� Company
<br /> 0 Certified copy m boreby hirnished
<br /> etii6ed ropy)e riled with,the ?v.iron+?aural 1104101 Dcpnr1i
<br /> CERTIFICATE OF EXEMPTION FROM WORKERS'COMPEPiSATJOO.N INSURANCE
<br /> (Thit stolon n.wt rqd fie mmpli Ii the permit is(f.r Ana b n.dred 441fim(j1(10)Iuless)
<br /> t ccd liy that in Vic pe,rormaaea of the work ftr utllch Illi.pfdellt It lacked,1 ORA not enlplay mty lu"on 1A.fly 1wiui;r en as to eocnntd suojerl to the wnrtdri
<br /> Cnn,ptilaat)on 11149 Ari siifnrnia.
<br /> Date: Applicant
<br /> NOTICE TO APPLICANT:it after malting this Genlfici of Fmcroption,you should bocoota at.bicet to(bo Workcrh'Compensation
<br /> provisions c•f the labor Code,you must(orthwi(h comply wilt ouch provisions ur this perinii shall be deemed revoked.
<br /> CONSTRUCTION LENDING AGENCY
<br /> I mrby airrnl liar Ibeln•h a conan.clian lendinp aW ncy IIi.IAB pedbreiii oftke work fnr width tb)r pam111 la i<>ucd(Sii 3111(;tvtl Cvdq
<br /> 'Lender's Name
<br /> Lender'AddroAa
<br /> DIVISION OF INDUSTRIAL SAFETY PERMIT CERTICATION
<br /> 0 r harlot'eerr(ry that.i,r exaavnii dve(d)or mivu(.ten In Je Nh Ano orii n laoW t.'N'A d 141 d-ti all[t.c mad:in eni.Acvtital o lih work niAhnrfnfd ll)'tic
<br /> pemru.And lhnr nobuildinli w id.rcadfrltli.i rels—oeh,(w d,,ir oA nr dielrnndtnp Item will k rtlnfr isso lhiny-ala Ur))(car li(1;?wultr3.2,flmnp'.Al iiNa
<br /> a,S&Hon sal.I'ido A,C'AllroroiA AdmtoirtrAlivr
<br /> 0 As owoet-builder,I will not eirli ltf)yore to do work whit b would«attire:t permit flvm the Division of Industrial Safely,Aly notlxl
<br /> above,uhlcAll mull person bast a permit to do such we*fron)the divislion,
<br /> ❑Division of lndostriol Safety Permit d
<br /> 1 m.11(y 11..1.1 haw.eed t1i.pptlul(nn and iii Ili the xlwm lefri illlLw 1.correct,I upraetA enmpty nrhh as alt,and ce—IT erdinii Aar)441e lawi
<br /> rvlati to n11 maSlY,,UI.A and Ar iiii rYSlaAe nnns ion.AnA 6will r ou'l of rgl"scia ativq,ri i te.elter upon filo ahnvlrrgclulonrd proli
<br /> Ar In pt.c**pu riou-
<br /> MID41-02-ra7 WN) 6lCi Ntikp('.OrftAAFTflFt9 ApCLARA7)1'N.Aoc
<br /> W I)M_N?
<br /> 313 abed `3Z:q[ LO-AON-93 e•OOl£ TaOjase� dH :A9 luaS
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