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Home My Public Portal About4928 GLICKMAN AVE_Plumbing__ RKERS'COMPENSATION DECLARATION AF ICATION FOR PLUMBING PERMIT I herek rm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76A667A or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS Policy No, 3641-92 Company State Fund Certified copy is hereby furnished, BUILDING ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 4928• G1icltC an"Ave. Certified copy is filed with the county b ilding inspec- tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple Cit Date AppIP-pgressive Plumbing WATER CLOSET ' NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB Q CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE SHOWER OWNER Texton•,Construction (This section need not be completed If the work Involved by / MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK - CITY San Gabriel TEL.NO. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER / �/- CONTRACTOR progressive Plumbing Date Applicant CLOTHES WASHER ✓ ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY Baldwin Park TEL. No. g62-2428 with comply with such provisions or this permit shall be STATE 478794 LIC' C-36 deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT NO. =PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 / GAS SYSTEM OUTLETS 5— f - (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �j r . and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION - -. License Number 478794 Lic. Class C-36 DATE U. Progressive Plbg. FINAL Contractor Date BY --, IL i I am exempt under Sec. B.BP.C. for this reason _ - IL' Plan check fee + l•i=f�•a(�;� Date: ��•Z PLUMBING PERMIT ISSUING FEE$ a �� Signature 2 TOTAL FEE ✓ !"I'?..I_i.__(.a`.'.i. .y?�_`��irf'%� Plan check applicant _c{` Z: 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-mentio ed'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o Permittee Date :R'S COMPENSATION DECLARATION 20-0026 DPW 9189 7 I ILII I hereby affi I I have a certificate of consent to self insure, 76A667A APP :ATION FOR PLUMBING PERMIT or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab. C.) Policy No. iM131)Z!� Company--ZleNZ'S_ 17-u'NO COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS � DEPT.OF PUBLIC WORKS DIV. 'lt ❑ Certified copy is hereby furnished. BUILDING ��tt (� FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS �-t Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY?Lyth � Date 17-1 1c17i Applicant�� i� �� WATER CLOSET NEAREST ,O�� CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.L- ASSESSOR _ _ COMPENSATION INSURANCE MAP BOOK_ :335 PAGE L y PARCEL (This section need not be completed if the work involved by the SHOWER permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORY ,y is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS become subject to the Workers'Compensation Laws. DISWASHER CITY L,/1- TEL.NO.ZAJ(pZ\4)SS Date Applicant CLOTHES WASHER CONTRACTOR �- Go 4- $-' NOTICE'TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS I 10 5 1,AO V.,&-sPAe_ provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY-5AJj /jAi3'(I e_k— TEL.NO. alq 7_26 00 I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of Division 3 of the Business and STATE NO. ��Q��'�ti CLASS 13 U i LIC. 0 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENOUTLETS OVER DISTRICT NO. PROCESSED BY m 5 PER SYSTEM License Number 1Lic.Class 6 )" FINAL VALIDATION W `}j C7.TC�N &0lSS T Z 1+��G DATE Z j�_�TJ 1J a Contractor Date l CD ❑ I am exempt under Sec. BY AL Z B.&P.C.for this reason Plan check fee Date: , Signature '- PLUMBING PERMIT ISSUING FEE$ TOTAL FEE Plan check applicant - SINGLE FAMILY .t HOME OWNER-BUILDER DECLARATION Name a I hereby affirm that I am exempt from the Contractor's License Law � 1 t,•; z for odthe following reason (Section 7031.5, Business and Professions Address (O'Ok ES O bdIA0P, 'T�CtL'S 0 iI 7 ;{� City Z„/a Tel. No!D; o1 (g5 . ' 5i� `i ❑ I, as owner of the property,will do the work and the structure -!•I_Is is not intended or offered for sale (Section 7044, Business ;;; _ and Professions Code). , - l'r" -69.31€ ? CONSTRUCTION LENDING AGENCY � r I hereby affirm that there is a construction lending agency for the s f` `•1 performance of the work for which this permit is issued (Sec. 3097, UAL 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 rr.e.�resentative of this ounty t ter upon the above-mentioned fpers, for' pec 0 purpose SEE REVERSE FOR EXPLANATORY LANGUAGE i;� IN `I a ' /( ig ature of Permittee Date r