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Home My Public Portal About4918 GLICKMAN AVE_Plumbing__ RKERS'COMPENSATION DECLARATION AF ICATION FOR PLUMBING PERMIT I hereE rm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A lul or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No3641-92 Company State Fund ❑ Certified copy is hereby furnished. ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county buildin inspec- ADDRESS 4918 Glickman-AVe. tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEE WATER CLOSET LOCALITY Temple Cit Date Applicant Progressive Plumbin NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' '� BATH TUB �� •• cRoss ST. Lower Azusa Rd. COMPENSATION INSURANCE OWNER Texton Construction (This section need not be completed if the work involved by SHOWER • �i�-, MAIL the permit is for one hundred dollars ($100)or less.) . LAVATORY oADDRESS 1103 S. San Gabriel Blvd. # I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK F/ CITY San Gabriel TEL. N0- 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth-' LAWN SPRINKLER SYSTEM CITY Baldwin Park TELNO.962-2428 with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION / DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER ' !J and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION DATE ®; License Number 478794 Lic. Class C-36 - 0, Progressive Plbg — av AL Contractor Date _ Elam exempt under Sec. pLf, B.&P.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ _„ , .! '•. ``�_ Signature — _ TOTAL FEE a;ryr'- ,, Plan check applicant i";i a 1 E SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 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, 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-menti d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign lure of ermMee Date :R'S COMPENSATION of consent to 76A666DPW9/89 APF 'FATION FOR PLUMBING PERMIT 76A667A I hereby affi t I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) ((�� COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy Not 2150�-12-1 Company ;✓� �= �� ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING �y� �a �u�� Certified copy is filed with the county buil ing inspection ADDRESS . 'T U y departure t. NUMBER FIXTURE OR ITEM @ FEE I LOCALITY Date Z Vi Applicant WATER CLOSET NEAREST CROSST. LOW�� 7�SA CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE ASSESSOR y (This section need not be completed if the work involved by the SHOWER MAP BOOK �� PAGE �� PARCEL�� permit is for.one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS�P L 5 lhLD�(lAfvs� become subject to the Workers'Compensation Laws. DISWASHER CITY LJ", TEL.NO.�L�i (_� llgS Date Applicant CLOTHES WASHER CONTRACTOR // wV_1 NOTICE TO APPLICANT: If, after making this,Certificate of �� N �>'((>ueq)v--J Exemption,you should'become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ° provisions'of the Labor Code, you must forthwith comply with such gDDRESS >pqJ (j-i PfflM�_- provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY,5piJ G'�7&�i.1�, TEL.NO.Q Jg ,,&609ja I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000 of Division 3 of the Business'and STATE LIC. ( 9 ) LICENSE NO.�9 .� CLASS Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS OUTLETS OVER DISTRICT NO. c PROCESSED BY 11: _ Fj 5 PER SYSTEM �®� License Number S� � Lic.Class ` - J FINALU t- �myT , I L� �� DATE Z. �U� VALIDATION Contractor Date - L U) F-1FINAL Q�j I am exempt under Sec. BY �O�J B.&P.C.for this reason Plan check fee , Date: ,/ PLUMBING PERMIT ISSUING FEE$ 74 Signature El ITOTAL FEE �/ _ Plan check applicant _ SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law _ for the following reason (Section 7031.5, Business and Professions Address 4 3 {7 Code): A y�p (..D D l � " UttG Q•a1•� �S O •�•:,'_. .r;�`��_j City Tel.No.2.1, (07-q (S�s ❑ I,as owner of the property,will do the work and the structure is not intended or offered for sale(Section 7044, Business001. };Ir(AL -9 __F and Professions Code). CHECK CONSTRUCTION LENDING AGENCY t� I hereby affirm that there is a construction lending agency for the CHANGE o�I! performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name 2 1 AN.ttirw_ Lender's Address I certify that I have read this application and state that the above , information is correct. I agree to com with all County ordinances and State laws regulating Plu inand hereby authorize representatives thi Co, my to nt upon the above-mentioned propert far' t!tl r ses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date