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S-AlM 3 Or Cmrttw E�t0 Mea"Demortment <br /> YV ELL &6ORiNG k;'EftMff APPLICATION bUPPLEWIENTAL <br /> AM ADDRESS- 'FERN vvp ilk <br /> L[CENSED Cn..NTRPP,,Tr,-)RS DECLkRAT IQN <br /> I harpby affirm trial I am*,-artseld under lhp prr*mlons&Ctmptpr 9 Immment'rnq with Ssc ton 7000)of <br /> Divison 3 of ine Catifomia business ciM Pmfessions Owe aria my kcense Es (vt tuft fosse arm effect. <br /> 1' 06.7-'12,D9014 <br /> Print Name*. Kao, R Sftnm-- 9-,M17 <br /> WORKERS' COMPENSATION DECLARATION <br /> Dera of PF di—I.:70 <br /> have- and <br /> as <br /> `r,:) I-j c�jj Ly Co-I iDn --,-T-`L) z, <br /> jil <br /> permit!s issued. <br /> I r-ndln.fm lh( ", Tfrv--arnt,&the.vr.,xk f1hic,pv.—, ,�t n My, <br /> En"I' m 127-- lam.;-4-h <br /> TIE' <br /> c"'Itri ct—! <br /> -02 <br /> WARNING: FAILURE TO SECURE WORKERS. PENSATION COVERAGE IS UNLAWFUL. AND SHALL <br /> SUBJECT A" OfPtOYER TQ CRWMAL PE"AtTfES A CWV;- FNES 'UP TO SIMON: M <br /> ADDi7w)Z44 Yo Vila c0lir, Of COMIP'r-LIhSAMN, vtkYiLkESt. Aiv0 GAMAGE-S <br /> Alf H 17A71 FO AN r-ii7 Pp--RAA;T LPP; ;0-4T!r,.N <br /> sft <br /> authori2atioll Ps valid for cme v f 1 t <br /> to the woo A iian da on rE frofli oacie of[his.aoo4fatk>p. <br /> END 2"18-1-2017 <br />