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CITY OF SALEM
No. L'A Ow 111301,4r
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PUMM PLL OUT LAMMY A OOMPLMLY TO AV=ONAYa N PAOOYr
TO THE INBPBCTOR OF su Loom.
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Workers' Compemadow Inwrance AlfMWk
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. . wh A prka*W place of bodma aes
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do hhereby'certly under toe palas and pasildes of pm*ya thaei
1 an an employer providing workers' canpemdm coverage for MW sitlplWou working IM
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Insuranp Cenyangr P Nundw
1 am a sob proprierw and hew no one working W me in any caoedq.
0 1 am a sob proprietor, general contractor or homeowner (drde arse) and hove bited tM
comxacton listed below who-haw the following workers' conapensstioe Posting
Coetractw insurania Company/PolhW.Numbw
Contractor Insurance Compstry/Po tumor
Conuaaor Insurance Cvngw y/Pvft Humber
O 1 am a homeowner performing all she work myself.
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Signed this . 361 day of 9 Bel e� G D V
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Seiectmens Office
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