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i <br /> San .�s��vin� t=,•.�f►�►,,n,�sal I.leattl,'DMSMtrr�er,+ <br /> VVELL + 6MkNG VERfiBlT APPLi ATION bUPPLEMENIAL <br /> JOR AilMESS- � .- � 'T,I 11 �1 'PERMIT V#P <br /> I haretry affirm that i am ft*nseld under tnp prrnirstons&'Chspt'ar 9 tcrnrrmanc�nt7 with Saction 7fM)at <br /> Dtviston 3 of the Caiifarrtia bustness and Prc4essions Gcoe ants my license is icy tutt farce and efsecz. <br /> < j ori C',n. �r•..� <br /> Prink Name. Kart, Da+�p' N-_w�9.2917 <br /> WORKERS' COMPENSATION DECLARATION <br /> �-.•'r-F'., jsr-;...� .1�Ia�' G*��ia.,`,i ,�(�S:.t J _ .c ,-.. �. '�i<�'r't�7 C�Cu�fl�ui.IJ�'�. :I7f.t' :F•i'. <br /> tme amd.nx:11'7 1..���':'V r.rc r+Ll;Fi �4c mf '7rtcc-r.1!'J.S9:h-w^�:.r�fr.r oir.rlrr:m' rrmnr,r rJcwafir�.ri c <br /> Sc:ifv('1 :-'�� �' :...[.��.n-%`t��". {a i.� r-l�' _ :: ��T I'7. .ice. i'_'(' <br /> permit is issued. <br /> �',^t i7^ •r-1-"._ nvif ark:' ^n Irl t!�rt ,``v•r:!':.� _. .���- :-'r" _ <br /> 1 n`.r,R!:^Y+ln f)r!h(- f,^S;.ryman t-:-,f the.Vr.V Ithik!- :... t .; v."^rke..^`.' <br /> compensator first ran e=earls:and .^c1`cv n_,mbars <br /> Carrier: Siaiviond �T-aiivy + a te i cx�.. Dwkw, $aea.i�iepa <br /> °I1i5� - I-7 <br /> chn +trf h^^ ^ten c. hi• ••� en u�ntifl�rc` r•r�rr.--•-.t.- r.� •rc^rc ^f ti'C�+`1a/+n Q i'. 'r c, -.1-.•_r r-•-r+6�1 i_ _k- - 2, <br /> --.. <br /> r Sign?tare• J <br /> WARNING: FAILURE TO SECURE WORKERS' FFEINSATIGN COVERAGE IS UNLAWFUL. AND S"ALL <br /> SUBJECT A" 'E'HFLO`+f'E'R TO C,tR'IM'MiA, CIL PENALTIES Attu 'CML FI'N'ES '0 <br /> UP TO $106. W M <br /> 4 f1L+u. Y tV Y1 i:: V <br /> 60. C GVWEhSI1N, 4,t7Zt{C 4+ A1711: KkN..I'S �t,ES, AAA DAMAGES <br /> /SI F�tt�i:•?ri t�;i N ri-kp ►iTi-+FQ THAN C-ST q;CNlNr, PFRMIT APPI IrATi('N <br /> heresy authoctze <br /> aut►wr 4a{ion is valid for one r r-p to the worm Ion da on front Daae of this 300ication. <br /> t <br /> EH7 2"18-1-2017 S4e+-Mahn WelUf w-m Pe"M Acv+-ptx ^ <br />