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Home My WebLink About0874A (4) WORKERS'COMPENSATION DECLARATION I hereby offirm tho� I have a certificate of consent to selt - a2-0002ovwaie� � fnsure,or�certiiita�e of Workers'Compensotion Insorance,or � %"""`"" � a certified mpy thereof(Sec.3800,Lab C.) . ce aos ��`��,�� E�� T PolicyNa Company___ _ � " p�s cC�p� 9^r p/� �+ ��Certified copy is hereby furnishad. �� . 4GYYEI� ^ ��qg�°tVE DSSPOa7lS� - ��Ceerti feden}py�s f'�led with the cou�ry buiiding inspection COUNTY Of LO$APIGBLES �UILDING AND SAFE7Y P;��Q�A'j V� .i)1.es't & 5on I.nO, Ft�R APPIICANT TO FILL IM - y f"7-`" e4)NNECTION DATA Dafe Applicanf � - . __.. CERTIPiCAiE OP EXEMPTIUN FROM WORKERS' � � �""'m"" -� ��- - e�aoiNc nr3�"1fl iz_ sr�,noN � oEan+i./� ----� COMPFNSATION INSURANCE - a.noaEss c. ,s ,,a"L�}'¢ {iqtZYr�"�'� j,l�.'"� ��"�-�(_.= ..,, �„ (This section need nor be compieted if.the work involved_by the iocaurr .�:e.$dtlGY3f�, �'d1'� r�uti�oi.F REFEREvcE '��.'�'� i.�J` i PwEk permit is for one hundred dollars($100)or less.) .__..—_ NiARiSi TVPE CF GOM1'NEC'ION �,�^"� LENGTH FROM I certify that in the performance of the work for which this ckoss st. y_ t��ag y�,_�.} rd,�io P.�. ��.3 - permil is issued,I shall not employ ony person in ony manner _ — —�— ; � � � '�Q rt� .:�.��Q� Z S�i�i m�n S_n.. , n m p ... .. . �:.. m�n -on y��- � O �zc� c � . . ..:�� . ... Z ....,,- ' 4 fi.v.�m CS�Ti � .�)C .'0�.1' � � ' . . ..�iR��-f1i �� 'y� D'N !{�--: 1l ��q . .. ��`oCt �u° rt,a �o�} p W . n c n� � �q �„v '�� a G a `rn R rc� .�.0 '�. N PJ� � - . , �"�� R� �"xi T �� F � � � ` m � ` � . � . � �. . � . . � � z � � +�s -. � m¢�, N � � � , � . . ,. ' ' � . ` m �� _ � � . .. � , � .�i ,� . . ,�,_�' .. � '� .t��, � .. . , . ... ' . � �� ' : ' � � . , J.. � �� . � � . . � � � ' t � t �- .. � . � � � �� . i. . �: �`��`.. � � .��. j �� C�� '� i - � �'� � �� 1 � � �� " � ; ;. � �� ' �� ,1;,. � ` ° � � � - �, 1 � �. � ,Y4 � � , � �# ` ` � .4 ` � ?; � } , '� � �s � _ p � � A �C�.�r� � �g � 1Q � � M ve C �.�6 tq�C '•� � .�P t�b ` '� rs""°p�°� � F+` p Ca '^ e� d.''�m � � �1 '�c�A S: @ e1'�h `°� ��`Y� 9'Q v! e e"g� E�" �P C � S'�'� ..� . . "��g'r!�.�v� � '��t -ar-•q� � �" � '°` cs `n �;g O �� ..q °"� A �y h '� p� � .. ' � � � �. �.��. mo�p'� o'�� a�� ~ � � �A.��'� e•m p"�a+� � .C � H-� A.A SO�" � � �� `"'°aa � .� e" �q `° ��'� o`�,'r`"is-'��.�� ro �°'�a.� � � � a � � , �.. � � . � � �� °a.m��w€e � ��-+� n " ��'�� a�.��:.x�a� � ` . '-:,�A "' m^»a ' !�:��`a.4 en. =� �r°'.i.. ea CS r � .. . . . . . G � w�� +,�,, � � � � �...w° a-o�� o ��° �.K � t`p�. � . . ! �'�,. � ��°�° �o°p:fl.b��,�� o ,�-�„�°;,��"' o �.�,� C�1 � . i � � � x �° m �'e`��'" °'�,�,�'1�C � �•� t`_w.��m w.� ��n ro �.. .. . �'' s-k O� • .53.:F''°�O`O,� C� � tay �c� .3 Y.�...�,�, r�O � . . �" $1�%' m+n q� u �' w .�.e.� `y��"' N'�9'�.� .�,'��eY..'n� � � �. �,,,a � �., . � WM' O r* - � ' . �G. `,'�` S � ia. �""�"°�.��rt� ��z�..p C��,'t5 W.n,A::n ��' ti� � �� 'rt �;�'�.�� '„�"t �,,�, �,�K �'�� ,�u e p � J,��v�s`ra�� o � �roo � ;'� °� � � . _ �'� w � �•,,,yy� � �3 � �.t Fn r� m � "'^� �. � � W � � _•�i'``,:a'�``� c �o a N s� . . � - . `� � j � .... � 6 Q'� £,.°�-:�a.� � Y? �.ia �� p a � ��C . p ,G�c�a W �, �� m �^ `��°�� ..��w�°�v' . €, . � '—�.a-m -�n. �. o � � - g. � ��,�p m A ` � _ � . . °�°'s � -�'�..N,�. 6� � �� ca��-s _.... � � �� - .. . �.� �'��'�.°. _.,..�� .�m