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2,761 <br /> JOB ADDRESS: o'er - _ ter � SF+Jt.-_. <br /> UCENSED CONTRACTORS DECLARATION ILCD <br /> I hereby a-(M Utah Ism hcermed wdw the PVM$i ux at chapter 9(clT'rwrxffh9 cmcF}M rxveslar j <br /> 30,tr a 13a and Yro%se+orm corse and my M rn 10 tXCB arrt r tfattt <br /> ucww `� ` — _ -r, r*w <br /> T'Aie -• t� !,Y-3 °� "� U/1,. <br /> WORKERS'COMPENSATM DE-CLARATtOM <br /> h_,,by adfrm under pevw y e4 pommy cele of the kh w rq doc4vatxm 4C4if.CK ONE) <br /> i <br /> I have and w�i!m�tdaia a cert ate a(MnSent to send a+ rfe h�w rvsa'c ur+oeresit art,as tuov tkxf(cr <br /> try 52r�tan 47�Q of il�e t atxx C06e,for the Perttxrn uu�Of U)e worlr`,-as rrRtyclt 1lns pwyn#is Rssan o <br /> I hmm and wig m&rttain wotkere compertsabo 3lnatame.ac,re+uvw by seczm 370.0 ao the Latxu Carse, j <br /> - iGr the perform[unoe of Me ncxk for wt�ttuS PMTN9 mrsvJed Mt wcrketrs'oorrrper:sat,On uxatra Ice <br /> currier art9 Ply rturkers are <br /> i <br /> y.t_i,_>r^i C b S Park►Number Carder,..,_.L--� �— <br /> 1 wtsthr oat in the Pe0owwK,e of the wlxk fir whoa+thea oerwA is issued,1-that,not emy+OY any Pte.to i <br /> any merww$O as to become sub$,Act to the a+O Wt'crxrytict anion imm of Gawarrwe,and agree thm d 1 '' <br /> shoLki beaDn"stbad to the workers OOmpertsat+m F df Sas kxt 37 ex!°ttm taoOr Cade.1 s+*aI+ <br /> farCt+vrth comply ar9t ows0 P ow"1or>~. <br /> j rt <br /> E3w a*vr+taate:� - <br /> � <br /> Pnntedlteune: <br /> WARM*Gr FAMA)RE TO 3ECURE WORKF.RSS'CONWEMSAIIOW CDV�"F-ISUt L^WFULI AND SHALL S WFCi <br /> AN EiwLoyER TO CRUNNAi.peiALTXS AmD CIVIL FMM UP SO ONE MR04tED TfIt SAND DOLLAR f <br /> fS,M,"*_L IN ADDUI M TO TME OM OF COAPFirC' llo".WMRWT.ATTORJIt'^f'5 FT-M AND DAMAGES AS i <br /> PROVIDED FOR IM.SECT"?70t OF IEE tAPOR G9LtE <br /> AUTHORIZATION FOR r�mERTHAN CST SIGNING PERMT APPt KATION <br /> I,stgm(tris San 3oa(pA n C cuobq 1Met1 P.rrart Appl Win^an My i rMtR I undeestwO#hiss rr�on �7►ow ie vatiQ toe <br /> i <br /> (vara(y)year and is Timcera m eh.Mrork pier,ta».d on ttne tror2 page of�nf+appT�crti�n. <br /> {a-papa t Ira -_ _---- <br /> 622r.� <br />