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Home My Public Portal About4938 GLICKMAN AVE_Plumbing__ RKERS'COMPENSATION DECLARATION AF ICATION FOR PLUMBING PERMIT I herek Im 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. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ; Certified copy is filed with the county building inspec- ADDRESS 49381 'Glickman Ave. tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEES L LOCALITY Temple Cit Date Applicant ogressive Plumbing WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATH TUB CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE _ OWNER (This section need not be completed if the work involved by SHOWER Texton .Construction MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued;I shall not employ any person in any manner SINK CITY San Gabriel TEL. NO' 286-5691 so as to become subject to the Workers'Compensation Laws. / DISHWASHER / r CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER / ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F you, Exem tionshould become subject to the Workers' SWIMMING POOL RECEPTOR P Y I CITY Baldwin Park TEL. No. 962-2428 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE 478794 LIC. C-36 deemed revoked. WATER HEATERICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION / DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS fY "� [ Gr (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O and Professions Code,and my license is in full force and effect. 5 PER SYSTEM S—f FINAL VALIDATION 478794 C-36 DATE 11-1Z•gZ ®: License Number Lic. Class Ca. Progressive Plbg. o� c C FINAL Contractor Date BY Q ❑ 1 am exempt under Sec. W, B.BP.C. for this reason �+ Plan check fee Date: �� PLUMBING PERMIT ISSUING FEE$ F Signature TOTAL FEE Plan check applicant 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. 7_-ht!'-7W ❑ 1, 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). +I_I'�_)'(_)> U.1 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 d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1. 3- 7-,.f-- Signature of Fermittee Date VR'S COMPENSATION DECLARATION 6DPW9/89 APP ATION FOR PLUMBING PERMIT ll 76A66 I hereby affir•.. ...... I have a certificate of consent to self insure, 76A667A or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No)''30-2-1t 57• CCS �u!"D COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Company ❑ Certified copy is hereby furnished. /7 ❑ FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING -T 4th3(J Certified copy is filed with the county building inspection ADDRESS l department. NUMBER FIXTURE OR ITEM @ FEE jy�- LOCALITY ��M• 1..E G Date 4 Applicant T� f-'r7 WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. -ZU COMPENSATION INSURANCE ASSESSOR r (�� r (This section need not be completed if the work involved by the SHOWER MAP BOOK ��j� PAGE PARCEL S permit is for one hundred dollars($100)or less.) OWNER S-T&P T,5 Dei/', 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 7A 'k �' j ADDRESS &0k 'j F16UP_1•✓o (O SINK S 0 become subject to the Workers' Compensation Laws. DISWASHER CITY �,�Cy �*g L i.( S TEL.NO."'►c A 61�4 15 S Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of ��k�OIV � ? Exemption,you should become subject to the Workers'Compensation /SWIMMING POOL RECEPTOR Ic7' f Sit✓ Gla i;�•l 1r 1_ provisions of the Labor Code, you must forthwith.comply with such ADDRESSI S 14 provisions or this permit shall be deemed revoked. ' LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY SAN GJ&-(2vl45 _ TEL. 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.GAS SYSTEM OUTLETS LICENSE NO.S'709-( 8 CLASS 13!� C)O Professions Code,and my license is in full force and effect. - OUTLETS OVER DISTRICT NO. e PROCESSED BY I: 5 PER SYSTEM 0 "License Number ��0�►�I� Lic.Class $ V FINAL VALIDATION W Contractor ��x�'J�" CADate I'3ST ( �14 1: DATE �C�(� CD (D ❑ I am exempt under Sec. FFIINAL Z B.&P.C.for this reason Plan check fee , Date: Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE g Q SINGLE FAMILY Plan check applicant , !�- HOME OWNER-BUILDER DECLARATION Name j"T-&&T 5 (CEJ y -' I hereby affirm that I am exempt from the Contractor's License Law _ for the following reason (Section 7031.5, Business and Professions Addressnl 5 Code): t,/ Tel.No. F City � 155 ==;I I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business i 1-1 ='. and Professions Code). , +-Z. CONSTRUCTION LENDING AGENCY F�. -, �r. I hereby affirm that there is a construction lending agency for the ''"``{ performance of the work for which this permit is issued (Sec. 3097, 3,-1ilF�lil` mIE; 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 Plumbin and hereby authorize representatives his County to e .er upon the above-mentioned propert for' ctiI pu poses. i y SEE REVERSE FOR EXPLANATORY LANGUAGE �Jv/ � Igniture,Itof Permittee Date