HomeMy WebLinkAbout1773A (10)WORKERS'COMPENSATIONDECLARATION
CE -806GCE -806G (2-801 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to self
insure, COUNTY OF LOS ANGELES BUILDING AND SAFETYoracertificateofWorkers' Compensation Insurance, or
a certifiedd/
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op tthhe reof (Sec. 380 . C.) n
V lK FOR APPLICANT TO FILL INPolitylefty -
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Certified is hereby
New Residential Bldgs. &Pools EACH INO.1 FEE ADDRES
copy furnished. I& 2-Famil S Ft. $ — v. q• LOCALITY (( MQ
Certified copy 6 filed with the count buildingyg inspection Multi -family Sq. Ft. — EARES7 C
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Residential Swimming Pools CROSS ST
OWNER OR 1T
Date Applicant s nI// / FIRM NAM 6
Outlets: ReLight Svv(1 O nnU 1 MAIL -y-— O
CERTIFICATE OF EXEMPTION FROM WORKERS' t
Total No.
First 20
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ADDRESS
COMPENSATION INSURANCE Additional CITY Tel No.
PLAN CHEC