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_.• JtW uu•4f)AUIWe1 <br /> . �DC�arm»M1tafiJu.Ci+lAWtdoaLS . <br /> Ofite*oLdmytl{aUOn7 <br /> 600 Watsio�ioa S4tee <br /> . 77ortoy Mil 0'711] <br /> �'A!etb\\'Gntpte:fetien(,M1eev+nea AISldavit <br /> Aop0.eaoo LlCarrelttttn_ PLEASE FYINT - <br /> to,gH;g�Knnneth <br /> LOCAZ!UN i1 Taffrall uav •' <br /> CITY malshDCA S-rATE MA W CCDE 02649 PFLONE p 508_477.13459 <br /> O !am a M:meolvaar perfarinlog aU o�erk ttiyself. <br /> O 143%t sole peeprittor and have no ons w*ktgg in kAY Ldpatidy. <br /> CI i Ara An thlplayst providiAap we kers'wapensat on for my"[bytes iwot'ktpz o0 this pub. <br /> 1 au an eaplCyar Prevsding varkera' eoofp for ALL aopioyats working on .h1a job. <br /> Cotrv,apy <br /> AdGresl <br /> CiCy _Sure;r--Zip Cod*,____ Psom -- <br /> ;rs❑tancs Co.. ,V polk <br /> Y At —Eepiratiaa Dene <br /> O !a.z,a sole prcprittcr,8e4teral fontractor,e•homcowtxr(cfrcir owe)and have hired t1K Conmctoff N ted tclo,,who hwe tha <br /> fallOwt�g u•Stken'compensation paticiet: ' <br /> Ccmpa:y Nama <br /> Addreaa <br /> Ctry Su to Zip Cxda — Pham M <br /> Inswrm"Co. 'Policy A L-;plralion GAEo� <br /> Car.',pany Nana�_ <br /> i <br /> nCd ess <br /> Zia Cvdv— <br /> rs•:ran:A Ca Polky p Expiration D:ttt <br /> rl:ur\m secure toy uISO as raquifed undu SeetlDa;23k of?/.00 1St ran lead to t%&impatdelon afuimin/i Potattita of a 2x up Io <br /> .:.;C*. fX)anSot Att years' inlpvonment At wodulu:civ'i1 p/caiau in Ibda fefm ofa STOP WOPK OXD➢R 1,01t,fwc of 5100.00 a <br /> !1,'against M. I Qfldatataad that a copy of this at);taEMnemay Ifs forwarded q the p[ftee of Inva:bdartons rf t>H DIA for eo..uaaga <br /> !(trl<11Cn. <br /> I <br /> I.o arn0yenN EN rAa pet eli,i penofffp aJp�ljwrr Mar tAe Orferovt,m pro ytded aho„r it true and >r•ecf. <br /> s:'vf0 uttt 17 MkY 1999 _ <br /> •,n.,,n„ Kenneth Litvack t PhoaeP 58x.996.7837 <br /> Q NNi we aMr•au ot',w.r in la:t Y\a-b it e�fraltld Y elry w Nv'ao1r4w <br /> P\rrNvtiralrl/ __ _ LI PViidlnt a?am"t <br /> I Ct Cicen <br /> ana 8atrd <br /> M Iq�il'et C]tiler urml'r cAke <br /> M:A 1 i C Uaatth 0 pam"tot <br /> ItNMQ.\N Mti�ti <br /> Q OItMr - <br />