HomeMy WebLinkAbout1508AWORKERS'(.;: :'•EN:'^" -7\
I hereby affirm that � -- ,;,,, . ::r'.,,,,. :PI'
: nsore, or a cern4cate of o•oa"' ": r rvl- w :r' Insurance, or
a cera Led cop thereof i5 3f :'i'.
Policy IN --- _ Company' �.�;�r ®..
.�❑f CarnLed cSvq'' eEby' furnished.
IUCertiflec ropy Is filed with -he county building Inspection
dcoanmorrt
Date„ 8�2Q/ 56kppl:con•_ ,Ttrefma_22_.-_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
;This sevio•, need not be completed :f "^e work Ir:volvcd by the
permit .s for one h,Indled do'lars 1,$1001 or less
1 con ff 'n n +o performance of the work for which this
p -m; ,issued, : sholl not employ any person' in any manner
so as to L-ecnme s,.ble t to -he WrrKers' Compensonon Laws.
Da•r.--.-_ __Appllcdl,t
NOI"ICF TO APPLICANTif, after making his Ce•ti4cate of
n7oter., you shou'd become s„ blec •o The Workers'
j ins t
.�ion provisions of the : "':" ' you must forlhw•th
npiy wItT such brovls.ons or Shull be doomed
rnvok.a
I ICFNSED CON -Z- -'it e:• ('\,
I hereby affirm tl•a' I am ,. ,.
9 ;rammer : .., ';
nes, and P. Ii':•1 ",, : r ..,, ,no . ......,, I..:
effect �'J
License Ni,T be,_4_,_48_$7_._-L:c C\^ s_. _..%34
Con•roctar__ Freeman Dcn... --8/20/86
[- I om exempi under Sec --.-._ .of the L.A Ca
P:umbina Code and or Scr
9 A P Codic'or :ne following —sor'
_—____ Dole __.
OWNER -BUILDER DECLARATION
hereby off•rm Inas ' am o.—W From t:;e Contractor's Lice -,se
1,11 fn• Ilse Fo�'nwing reason ;