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Ili <br />I <br />II <br />13/,/z -,/7 <br />2 /3546-2270 <br />)q.t$flbr <br />M. Doffo <br />Es€iq^t: <br />1 vacant larIdry blctg. <br />d'LD|r.o.^ioUr. <br />2327 S.I',tain str€et <br />Conv.Move Dem <br />Auto BodY <br />7260 q. ft <br />E So"rlon ,O:r,aA l, .. own.r ol lh. groP''tv. ot ttTY 'mploY"t <br />wllh <br />7.-l - ir.,' i",. "ornpt"tttton, <br />wllt do th' rYo?k' tnd dr' 'l?uctu?' <br />tr not <br />tntandad or otta.ad toi aal.. <br />f] Sectton TOaaB l, .l otn.r ol tn' pto!"!v' 'm trclu'le'lv contT"llng <br />wlrh lic.na.d contr.clo.l lo contl.uc! lh' P'oi'ct' <br />Res. <br />O!1. <br />Ecist <br />I h.r.by allltm that I am axtmpt lrom th' conl"cio"' llc'nl. l'w therlndust <br />Ian]rdry to Auto Body sttot> <br />L00. x 902l <br />200 ,000tI18 , -6" <br />02-?tetoorl . <br />5 7/Y-7r, o 6'// <br />1 oto Noa 'p El. <br />Lalt? fo.;-r.t! i.Co. <br />'.r fl ,-R <br />r.lraDra rtrt.o,..6 .-E <br />'.jE ,."C1 <br />AOrUtlralxra <br />tsuite 309 <br />,I toro <br />i.lIcth <br />aIBu3 <br />g.*-Ai!- <br />D.t. <br />105 W. Fourth Street, <br />t'Sq, >f../3"4/.845-229270LSatta Ana, CA <br />t <br />/o. oC)a\&(\) s,-re-- <br />Jli tu,/ . )f <br />234 <br />lanvria(-on)-i l-,'o'l.s o <br />124)-ElU <br />UA <br />- <br />rcRKERS COMPENSATION OECLAR <br />t c.rril, rh.t ln tha p..tdmtnc. ol iha work <br />I .hall nol .mplov t^y Pa.ton ln 'nY m'nnlr <br />lYo?k.r't Comp.nxtlon Law. ol C.lllo'nl'' <br />L.l1d.r'r add.._ <br />APPLICANT'S DECLARATION -....-- <br />-- <br />I ..rrllv rh.t I hav. r..d lhla.ppllc.llon 'nd tt'l' lh't th' '6ov' lnlormdloa <br />;;;;.;,. -l .sr.. to comolv wlrh .ll ciiY orclinrnc't rnd !tti' ltwr 'il'tlne <br />to o.tlot.e conrtructton, and h.r.bv lulhorl"' r'pr"nt'llvtt or thr' clly <br />r; ..t.r up-on rh. .bov._ma.i lo..d P'optriY loi ln'p'cllo^ Purporr <br />r. ol Appllc.nl or AFhl <br />?- <br />icn <br />lor whlch thii parmii lt laaua<|, <br />ao .t to bacoma .ubl.ct io th. <br />I h.r.by .lllrm th.l I h.v.. c. <br />tcrt. ot Work..'r ComP.nEtion <br />rtlllc.r. ot co^..nl to <br />lnaur.nc.. C.riitl.i :t-g{Cltv buildlnc lnlpGtlgn <br />".-))-l{ <br />rwL <br />ATION 1- <br />t.lt-lntur., or a carlit_ <br />a <br />--- <br />- /lq'aa <br />I <br />l <br />New Addn <br />547-762LDdE1il xrctee <br />O.ir-..-- ApPllcanl <br />NOftCE TO AP?LICANT: lt, .lt.r m.kihg lhil C'rilllc'lt ol Et'mpllon' <br />vau r'routa braoma oblacl to tha worl'r't comp'nEllon crovlilonl or <br />Li ull"11Ji, you m;rr rorrhwlth comprv wrrh tuch p'ovl'lon' o' thrr <br />o.rhlt rh.ll b. d..m.d ..vok.d <br />cotisTRlJcTloN LEt oER <br />----------------r h.'.h! illlrh rh.l th.ra lt . contttucllo. landhg 'Fncv <br />to' th' p"ro7_ <br />;;;;.; ;. ;;.i 1., wnrch thr. p.,mrr r. r't!'d ls'G 3oo7' ctv'c l' <br />a.,.o..,. r1.-. !,rorcury Sarri nge tltm DC <br />-q- <br />Daa"'o. ! <br />"? Pf/ <br />-s <br />' /t<., \ <br />?n t43'l_q