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Project Type: ❑New Constxuctian QRemodei ❑ I am a sole proprietor and have no one wo�icing in any capacity. ❑Building Addition � I am an employer providing workets'compeasation for my employees wo�icing�t th�is job. compasv rame: �_�if�_ f��..G� L;�r� �te��iE:�' �P _ ��: �SC� l�l� �h � � �.�-a2� �- �,e�: 1;1. ��� o�./� , G� �z (? 3 0�a- uro8 7 7�-o!o v � �. 'ew ' �� .1 , � . G�G p6S- g$-5d7 � ; � ' :� ;- e. .:,, F: . . � ..;. .�x >. .r �h-�. < -° < �� = p� Y.".. �.. " ..::. '....:^.. .. .... .. . .. _ . . u. ^"'Yxw:,R° ._ .. aK.G.�°�,`_ ❑ I am a sole praprietor,ge0eral coatractor,or homeewner(circle one)and have}rirad tbe contractors�listed below who have the following workers'compensation polic�: c�wiar iaat: address: c[tv: n6oxc#- eb. � • ' :�_ �n,�.�.� ; _ ,, s� , . . �,;�;�.-�s��� �Y�ame: address- � oiote�F- -__ ---- — - --- ----- _ _- ---— — — _ _-- — -- - , .,. ._. _ . , , - - - ------ - -------:-� _ _,. :,. - _ ` . ...�. . .. . �.�-.e: ...:.. . ..:::.:� ;,..:..� , >;a"';' Y`..F"s'.'�'�'�.i''7 sF�.x„:.�Si..aa3,:�:�:�."'.�.. 5.."�-�"�4:�'n�*�`r"��,.���..._,:�. r'�!r fEG1�ft C�IQ1�!S!�1�lf$!�9!�l+����.�!�1���!��C���f!git�a+f+�......�.SY�K . oie ynn'�pi6sueat as weL b dri pwdtla la tie f��t a 3TOt WORIC ORDER aad a 8�e�t SiN.M a day�'e.I adde�ud t�a a�ry s[1rh�t.m�6e fitwaMcd M!he Omee�[��f tlre DIA fir cwerage v�atlw. I i/o Ard+eby ce ' iueder �wApew�lhea nfPery�xrp t6�t tA�e iwfern«llo�prev�ded aboae fs�rxe wrd comrt s�� n�u 1�-a 3—�R e,�c� �1 '� �, r�,�# So g 7 7/ � D!o 0 .�dal.x eiry ao aat write i�this ura ts 6e a�le�d bY.cilr�r wwa�seacial . eity�r tsw�° ;,.�tl6o�e g OgaYd�E D�uUm�� Q ehat KistedLk tsapsme is reqaired � ���� �'s O�ae �Haltli Dqbr�eat cn.+iod s�20�• , .��'. �101�l'r