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,IUJhIJ --l r <br />N0z o <br />F <br />(A -! <br />1o <br />rrcr mo nsE <br />{"*Ad Repair Move Derr <br />I h...by .tlirm th.t I am .x.;pt lrom th. contr&tor't lic.... l.w lo. rh. <br />LJ S.ciion 70444 l, .r ow..r ol rh. p.op..ty, or my.mproy..r w,th <br />w.g.r .r th.ir !ol. comp.^..rio^, will do rh. work, ,nd rh. tr,uctur. i3 nor <br />lat.nd.d o. oll...d lor rr.. <br />L--J S.rtio^ 7(}Z]aE l, .r ow^6r ol rha g.op.rry. .m.rcrst,v.ry conrr..t,^g <br />wrth I'c.nr.d co.tractor3 to co^rrruct th. prol.ct. <br />Kq 5!9te{ <br />utherA*d <br />K o <br />Dat.- Owh.r- <br />i, <br />YVOR K ERS COMPENSATION CLAR <br />I h...by .tfi.m th.t I h.v., c.rtrlic.r.llu'ac.t. ot Work.r'. Cohp.ni.tion ln t <br />Cirv beildi.g in3a,.< tio. d.p.rtm. <br />",,. //- /7-8// <br />I c.rrily rh.l In tha p.rl ihrt p.rmit rr i.ru.d l+o*I .h.ll .ot .mploy .ny p.r .ny m.nn.r.o 6l to b.co6. rubl.ct to th.Work.r'. Cohp.n rio. L.wi ol C.rito,^i.. <br />NOTICE TO APPLICANT: ll, .lt.r o.kihe rhi. C.rritic.r. ot E!.mprion,you rlould b.com. rubj..r to th. Wo.k.r'. Comp.nr.r'o. p.ovi.io.. olth. L.bo. Cod., you mu.r fo.thwith .omplV wirh roch provrrionr o. rh,!o.tmit.h.ll b. d..m.d r.vot.d <br />CONSTRUCTION L€NDERI h.r.by attirm rh.t th.r. ir 6 co.rrructron t.nding ag.dcy to. rh. perto, <br />m.nc. ol th. work for whrch rhis p.rmir i. irto.d {S€c. 3O97 Civ C.) <br />L..d.r'r Addr.rr <br />APPLICANT'S LARATION <br />I c.rtity th.t I h.v. ... <br />i. co.r.ct. I .e... to . <br />.lro..nd rt..e rh.t th..bov. intorm.r'oh <br />.ll c,ty o.din.ncor..d tt.t. r.wr,.t.ti^g <br />bv .urho.iz. r.pr.3!nt.tv.. of rhi. c'ry <br />/z -) / -*/ <br />lSlqa 'tA'Et-71 <br />Nlcr< &atL.r,)o <br />o24oL getll uttD .s'f&*f <br />, <br />.r"Lrrlz ftl?c s'.<atf. a,t,il <br />tzl L <br />838'Lrtt <br />lic.ns.d und.. th. proviiion! ot Ch.p16r 9, O'virron <br />Prol...iont Cod.. .nd my lic.ne r! ,^ lull ao.c6 .nd <br />u,,.^-*^jfrlEQ crrs€.l cit",--""-4-as-57 <br />!o.,.4. Ht-rt <br />I h.r.by .flirm th.t I <br />3 ot tha Burin.r. ..d <br />, llo.ya t n) <br />l.'hiqr., o.. c6rril <br />N <br />fi-L <br />---- <br />o'/-/7 8/q9 <br />i. <br />I <br />I <br />llt lc <br />ra <br />44* tto <br />r r a,l. ri aat <br />-b-,ArJ\ s n^?r-E <cL-8ll? <br />,zl attu.a rt- <br />a6rt ;raa.4 rltb <br />'.. Ll <br />If <br />tr:':,:ii <br />234