HomeMy Public PortalAbout5612 ROSEMEAD BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION
CE 875 (11 84) MISCELLANEOUS APPLICATION
CE 876 n
I hereby a Finncert that 1 have a s'Compensation
of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION lull
^si,re, or a certdicate of Workers'Compensation Insurance,or
a certified copy thereof(Sec 3800,Lab C)
I Policy No Company FOR APPLICANT TO FI LL IN BwUoIow¢LDING
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Certified copy is hereby furnished euILD IND
AIL St- 12 Af 6L�V4
Q9! BM LOCALITY
❑ Certified copy is filed with the county budding mspectron Lo cw LlrY rNEARSeT
department X--+L� �' 9t 7� cwose aT
Date Applicant NEwRe BT /' DISTRICT NO GROUP TYPE PROCESSED BY
CROQY ST �II^u--P CONST
CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL
COMPENSATION INSURANCE DESCRIPr1oN LOT No BLocK
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