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r <br /> h <br /> fan ,la�irin iCtx:r+t+r 9'Healt'h 4enattrrx►nt <br /> WELL !:SMING PERMIT*APPUCATION bUPPLEMENTAL <br /> L CEN.ISED QnNe-rpfi C.*TQR,. DECLARATION <br /> I hamby affirm that 1 am'h ansar5 Lm6er thtz prr3vrs-tons&'Ctsap'int 91 cry, ,,, an6tnq wft Sartlon 71.)W)of <br /> Dwision 3&Me Caidomia business and Professions Code area mW kwense vs kn fuii fame aw eftecz- <br /> t-,Cwi'aac'lor Name. <br /> 44. 'J57•'r <br /> I .jlUilidillll�_ Y u 70#k'. /'' 74 <br /> Print Name. K-ml.i R Sh s Date'. N--mesrqbe'r 9,20!7 <br /> WORKERS' COMPENSATION DECLARATION <br /> i=ri,f .{r. Jrta$ r` "; <br /> J '.~.,,.y �e:'.i!;n :740 ':` t _ :�'�=�i...o,�i., {.�' h,.. _ .- .,.!. _ ,. , i':rC;�.�ic''• .;it,i <br /> r•fP(�'X1�tC ICCXJLZL. <br /> c.:c. 2.??w +�G'.. .'.''e'r•:I.c.'... P�•-.t,ru syr*; �n'SZ'm.��^>"'�.',:�:- '.r.�'1'.�i.--. ._ _ _ Y _ .. _.._ .�`� ... :. <br /> " a:+'!4s!:�x+,F,Fps*hc� xss*a�x? s'S'*� •er;rA i��.J :�r ,a.is. - ^-' "y.,..fir <br /> cortlDansatbr t I,7tS:'rF nce carrier and r-ol�CJ in <br /> Carrier jfiaieh)riti k l}}t' Fxv. ._.7'rFa.' $iM'Wi pa <br /> q 11 <br /> 'ry r_.� Yt:r'. f�i`Sf•f.'Td4iW vs' rev iwvr.Y iV� `I'id/wM. u1:N uwiw� <br /> :hn.irry t:•.-•.-�•.� Ci1�Ytlrt to . rto•r' ^r.-^rr r:c,•� ,- r! ti:^r!r�•n .-i j " ,..?'hc, ^�i-.•...r I�rs^n } - <br /> Vx- <br /> WARNING. FAILURE TO SECURE WORKERS' PENSATION COVERAGE IS UNLAWFUL. AND SHALL <br /> SUBJECT A% EM RL(:1YER TO 'Cfkff'CI r4Tr PF-"A'LTIES AM 'Cr4k 'FI'N'ES 43P TO Sl".OW: 4N <br /> titl►lkilL�i fii ►its ���i v i, a;'.r'�Y'� �i{+3.4. YtSrc_ni= 1+f 'iC3iM1Yhlt X :S rE S, F�J.la 1)AMFGS <br /> by:—v HnP; LATi ev Yf�tF?(�iTi4F-P Ti4A ri r—'37 P;:RMIT ADP; irATION <br /> hereby authocize — -- — <br /> aliii-iorilafion PS var►ci fog 4'-we v r tit' v.i i 'i: i€t YrVfM r'pri vel 6,)" hOfit 000e of thisaupiication. <br /> EHD 2"18-1-2017 Ste i{Afmatux+Wet�i3�r^rro�+�*Yt1 At�picatia^^ <br />