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� I I-iereby affirm that 1 have a certiticate of cansent to self 76P.6e7A � � �
j insure,or�q certifl4at@.a�Worke[5'.CQmpEnsatinn.lnsurance._ . �gF7(FtEy.;O/81).--- .. . .. - . .. .
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or-a certified-coPY thereof�(Sac.380Q:tab.E.}- -.-.. . .....�.... . � ... .-
�—.. GOUNTY pP tOS ANGELES BUILF}FHG AND SAFETY 5a �
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Cerrified copy es here6y furn;shed: dl�-�
� . . - . . . - WR APPlICAM TQ fltL ItJ(PRINT OR TYPE) - BUILDING.� R I
e�tiHed��cepy-ufifedw�i6the-county..bviidi��inspac ADDRE55 a�- 1
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-. .� �CE 7Q APPIiCANT tf,-after muking Hr�s-Certifrcate of . . . �� a[7FSRE55 . -. .. _.-�
a ptian. You�'should becpme sub(ect lo ibe-Wwkers' � S�M1`�lNGPQQtREEgPIOR. -_
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