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HomeMy Public PortalAbout4840 GLICKMAN AVE_Plumbing__ WORKERS' COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I hav�;acertificate certificate of corysent to sglf in- 20-0026 DPW 4/87 . sure, or a certificate of Workers'Compensation Insurance,ora 76A667ACE 817(REV. 8/86) certified cop thereof (Sec. 3800, Lab. C.) , Poli fj�1-2-� Company �J7/�?E A COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Certified copy is hereby furnished. FOR APPLICANT TO FILL IN (PRINT OR TYPE) BUILDING 'i' Certified copy is filed with the county building inspection ADDRESS 48 T® 6L4 CV-I'''fi6 tJ department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY �'P�—46t 7�� GL T- Date -�/`"2 Z`J l Applican z� WATER CLOSET(TOILET) NEAREST L' u CERTIFICATE OF EXEMPTION FROM WOR E ' BATH TUB CROSS ST. L_0 F__ COMPENSATION INSURANCE SHOWER OWNER 4 �� (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS I certify that in the performance of the work for which this per- SINK mit is issued, I shall not employ any person in any manner so CITY TEL. NO. as to become subject to the Workers' Compensation Laws. DISHWASHER CONTRACTOR i C.�Td I,J Ca�✓S � C� , [(� , Date Applicant CLOTHES WASHER ADDRESS �c93 gl `i a --tCZ(_ ;k NOTICE TO APPLICANT: If, after making this Certificate of Ex- SWIMMING POOL RECEPTOR emption,you should become subject to the Workers'Compen- CITY ler TEL. NO.411 ff- �-4.p l sation provisions of the Labor Code, you must forthwith comp- LAWN SPRINKLER SYSTEM �' [ ly with such provisions or this permit shall be deemed revok- ' STATE // �� LIC. ed. WATER HEATER LICENSE NO. 7 7CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. JPROCESSED BY I hereby affirm that I am licensed under provisions of Chapter GAS SYSTEM OUTLETS ®'19, 9(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER fend Professions Code, and my license is in full force and ef- 5 PER-SYSTEM DATE LC�j VALIDATION License Number � � 7 Lic. Class U FINAL / o Contractor -�T�N �'oi✓��cat � '� -22-�/ BY 0 1 am exempt under Sec. W d B.BP.C. for this reason Plan check fee Date: _ � -�` PLUMBING PERMIT ISSUING FEE$ Boo. Z Signatu TOTAL FEE SINGLE FAMILY HOME OWNER-BUILDER DECL ATION Plan check applicant 1 hereby affirm that I am exempt from the Contractor's License Name Law for the following reason (Section 7031.5, Business and Professions Code): Address ❑ 1, as owner of the property, will do the work and the City Tel. No. _ structure is not intended or offered for sale(Section 7044, -= y' Business and Professions Code). ® - j ) 0 0 CONSTRUCTION LENDING AGENCY -. - :E I hereby affirm that there is a construction lending agency for _ the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name w Lender's AddressRi I !=s_ I certify that I have read this application and state that the above information is correct. 1 agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . ,.-tel—a�•—`�� Signature of Permittee Date _.WORKERS'COMPENSATION DECLAPATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to'self 2D-0026 DPW 6/87 insure, or a-certificate of Workers' Compensation Insurance, 76A667A pr a certified copy thereof-(Sec: 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No. WP89363 ;pany Fremont ElCertified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑ Certified copy is filed with the county building inspec- ADDRESS 4840 Glickman Ave. #A tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Date Appliganptrogressiye Plumbing 3 WATER CLOSET 1-7.2 NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB 11 CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE 1 SHOWER .J�d OWNER Texton Construction (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) 4 LAVATORY ADDRESS 1103 S. San Gabriel Blvd.#H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 1 SINK CITY San Gabriel TELN0.286-6090 so as to become subject to the Workers'Compensation Laws. 1 DISHWASHER 715 CONTRACTOR Procrressive Plumbing Date Applicant ] CLOTHES WASHER - V NOTICE TO APPLICANT: If, after making this Certificate of ADDRESS 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITY TEL. NO. 962-2428 Compensation provisions of the Labor Code, you must forth- Baldwin Park LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. 1 WATER HEATER LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PRIs—�— I hereby affirm that I am licensed under provisions of Chapter 9 '1 GAS SYSTEM 5 OUTLETS � J�J• O(y 2�ESSED BY (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM g DATE 0, VALIDATION License Number 478794 Lic. Class C-36 0. p FINAL 0 ContraciorogreSSlye PlUmbi �- 1/ BY ❑ I am exempt under Sec. fl) _.gr �l �l B.&P.C. for this reason QPlan Check fee ® --. — q r— Date: PLUMBING PERMIT ISSUING FEE$ 13 — � •s-- fI i" � Signature TOTAL FEE �� �o } e1 TAI Plan check applicant fl gL�l'�. ty 125. 50 2—y. ` 0 SINGLE FAMILY !.ilClil _;.51 HOME OWNER-BUILDER DECLARATION Name CHANGE I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. ElIE I-1 {1 , as owner of the property, will do the work and the 001, 1Ur structure is not intended or offered for sale (Section 3072 1 AM 'P 45, 7044, Business and Professions Code). lop CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize represent t, es of this County to enter upon the above-mentione roperty far inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hpreby affirm that I have a certificate of consent to;sel6 20-0026 DPW 6/87 insure, or q 4ertificate of Workers'Compensation Insurbnce, 7 6A667A or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Pblicy N16TP89363650Coni pony Fremont Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspec- ADDRESS 4840 Glickman Ave. , #C tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Progressive Plumbing 3 WATER CLOSET ��yyy Date Applicant O' ✓�' NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB / CROSS S7. Lower Azusa Rd. COMPENSATION INSURANCE 1 SHOWER OWNER Texton Construction (This section need not be completed if the work involved by MAIL the permit is for one hundred dollars($100)or less.) 4 LAVATORY �0 — ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this �y, permit is issued, I shall not employ any person in any manner 1 SINK 67) CITY San Gabriel TEL. NC286-6090 so as to become subject to the Workers'Compensation Laws. DISHWASHER 1 CONTRACTOR Progressive Plumbin Date Applicant 1 CLOTHES WASHER 6-0 ADDRESS 4257 Auction Ave. #F NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY Baldwin Park TEL. No. 962-2428 P p y LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. 1 WATER HEATER LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. ROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM 5 OUTLETS �ei O /� ESSED (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER t7 �! and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL / 9� VALIDATION DATE (U License Number 478794 Lic. Class C-36 Progressive Plumbing( �/ FINAL ) q�s�n ,,y,� J' Contractor Bate J — � BY Q`!/I/ j ❑ I am exempt under Sec. e�J_.ar 0 B.$P.C. for this reason 52) - 1'' c- 9�.� Plan check fee _3C1 �•.501 cn. Date: PLUMBING PERMIT ISSUING FEE$ ' -0 . r Signature /� � J.a��� ,� TOTAL FEE CCS TOTAL 125 s 50 SINGLE FAMILY Plan check applicant CHECK 125.50 HOME OWNER-BUILDER DECLARATION Name CHANi3` ,[I*I I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and �,)1000_11300 ProfessionsCode): Cit Tel. No. I, as owner of the property, will do the work and the ✓ o structure is not intended or offered for sale (Section 3070 1 AN `4K` 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize repres ntatives of this County to enter upon the abo entio property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby, affirm that I have a certificate of consent to self 20.0026 DPW 6/87 �j irisuFe, dr drertificate of Workers' Compensafion Insurance, 76A667A ILJI ;;or a certified copy thereof_(Sec. 3800, Lob. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy N�89363650Company Fremont lJ Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 4840 Glickman Ave. F #B Certified copy is filed with the county building inspec- tion department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Progressive Plumbing 3 WATER CLOSET —D Temple Cit NEAREST Date Appligant 2;' v CROSS ST. Z,OWer Azusa Rd. CERTIFICATE OF EXEMPTION FROM WORKERS' 9 BATH TUB COMPENSATION INSURANCE OWNER Texton Construction (This section need not be completed if the work involved by 1 SHOWER �7J MAIL the permit is for one hundred dollars ($100)or less.) 4 LAVATORY b ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 1 SINK CITY San Gabriel TEL. N0.286-6090 so as to become subject to the Workers'Compensation Laws. DISHWASHER 1 CONTRACTOR Progressive Plumbing Date Applicant 1 CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Baldwin Park 962-2428 with comply with such provisions or this permit shall be STATE 478794 CLASS C-36 deemed revoked. 1 WATER HEATER LICENSE NO. LICENSED CONTRACTORS DECLARATION DISTRICT NO. P CESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM 5 OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION License Number 478794 Lic. Class C-36Q. DATE (� ®, FINAL -2 Progressive Plumbi -�- BY .'`GN qr-.. Contrac or a I @L ®, IDI am exempt under Sec. 33I e c- B.BP.C. for this reason CLI Plan check fee ► i 2OIZ6 Date: PLUMBING PERMIT ISSUING FEE$ /, il_TAL 125. 50 Signature g TOTAL FEE p2J [_i�ECK 145.5111"; CHANGE Plan check applicant a(}(� SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License [li_1clo--n)-'-(-'I I Law for the following reason (Section 7031.5, Business and Address1 101 i/,t 90 Professions Code): City Tel. No. 073 1 AM 1:50 ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the , above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mentione roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE r 1z2-/-,f41 Signal re of Permittee Date WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hereby affirm that I have a certificate of consent to-seFf 20-0026 DPW 6/87 insure, Dr 6 certificate of Workers' Compensolion Insurance, 7 6A667A or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 0 cy No.! 89_ 6365Qampany Fremont Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING © Certified copy is filed with the county building inspec- ADDRESS 4840 Glickman Ave. #D tion department. pp NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Date Applic6nOgreSSlye Plumbing 3 WATER CLOSET r-q NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 2 BATH TUB CROSS ST. IAwer Azusa Rd. COMPENSATION INSURANCE OWNER Texton..Construction (This section need not be completed if the work Involved by 1 SHOWER 6 j MAIL the permit Is for one hundred dollars ($100)or less.) 4 LAVATORY .40 Bp ADDRESS 1103 S. San Gabriel, Blvd. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner 1 SINK CITY San Gabriel TEL. NO. 286-6090 so as to become subject to the Workers'Compensation Laws. DISHWASHER 1 CONTRACTOR Progressive Plumbing Date Applicant 1 CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY Baldwin Park TEL' "°'962-2428 P P Y LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. 1 WATER HEATER5_D LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 1 GAS SYSTEM 5 OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER Gd and Professions Code,and m license is in full force and effect. 5 PER SYSTEM. FINAL/r VALIDATION B; DATE CCDD / 6/ ®, License Number 478794 Lic. Class C-36 0. FINAL Progressive Plumbing .� � li -� c Contractor ate BY _ 1 am exempt under Sec. A+•�•I IT W B.&P.C. for this reason D L 137 125.50" Plan check fee Date: e� _ + i I �:(_ Z PLUMBING PERMIT ISSUING FEE$ Signature .) TOTAL .'�25. 50 TOTAL FEE Plan check applicant CHECK 'rj SINGLE FAMILY t:f-(fh4t�E �I+ t HOME OWNER-BUILDER DECLARATION Name /1 I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and Professions Code): City Tel. No. I_l0[i[I^�ii Ei I� il" 1/91I ❑ I, as owner of the property, will do the work and the tiflJt tL 9:49 structure is not intended or offered for sale (Section , 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name Lender's Address I certify that I have read this application and state that the ► above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing, and hereby authorize representatives of this County to enter upon the above-mproperty for inspection purposes. ,,11 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date