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Home My Public Portal About4950 GLICKMAN AVE_Plumbing__ ORKERS'COMPENSATION DECLARATION A ■KATION FOR PLUMBING PERMIT I hen firm 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 4950. GliCkman •Ave. tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEE LOCALITY 4PyTTio iPlumbing ressve lumn � Temple City Date Appli g g � WATER CLOSET � S NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB , o CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE , SHOWEROWNER Texton Construction (This section need not be completed If the work Involved by MAIL the permit is for one hundred dollars($100)or less.) LAVATORY -20 ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK Al CITY San Gabriel TEL. No. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER vI' CONTRACTOR Progressive Plumbing Date Applicant r CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- CITY Baldwin Park TEL. No. LAWN SPRINKLER SYSTEM 962-2428 with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER — LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS 1 Q (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER o and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 478794 C-36 DATE t 13 License Number Lic. Class �; Contractor Progressive Plbgle - � eY AL ❑ I am exempt under Sec. W B.&P.C. for this reason 0- Plan check fee U) Date: PLUMBING PERMIT ISSUING FEE$ Signature fiS L I s c TOTAL 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 Address �,I...'. Professions :ode C ) City Tel. No. _ ❑ �}' I, as owner of the property, will do the work and the `1'--"j'•" structure is not intended or offered for sale (Section Pilo7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I_••'=111e 11"`'" `�`�=a'.% 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-mentiproperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sign Lure of ermittee Date I COMPENSATION DECLARATION 6DPW 9/69 APF ;ATION FOR PLUMBING PERMIT 76A66 I hereby affi t 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.) Z2 0-7— 5_r&TC— —1_,N0 COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS�J� DEPT.OF PUBLIC WORKS DIV. Policy No.1 1 Company {� Certified copy is hereby furnished. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS ��S GLACA4 A^,N Certified copy is filed with the county building inspection department. —f NUMBER FIXTURE OR ITEM @ FEE LOCALITY 'CLiM 1 U Date 11� Z Applicant-T Ek—Lt�rJ G(�IV ry ` WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. L oLA+t=/L- COMPENSATION INSURANCE BATH TUB ASSESSOR Q _ (This section need not be completed if the work involved by the SHOWER MAP BOOK US��7 PAGE I PARCEL permit is for one hundred dollars($100)or less.) LAVATORY OWNER -5—%p-,j7 I certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS �Q1 5 �)�I�ER�p/, 4J&gC) become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.N0.213 (pZq 155 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR ZE� a GONa�IL Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS ,,(,l provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY < c, ! - TEL.NO. (0()! } I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER o (commencingwith Section 7000 of Division 3 of the Business and STATE LIC. ) GAS SYSTEM OUTLETS LICENSE NO.JPO Oil& CLASS 0 Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM 1 J� _ Scam 0 � d� CSa-�� License Number S_7dQ• 91g Lic.Class � U FINAL DATE VALIDATION I W b`Z 0. TES- aN C•ot�z Contractor � Date 0 El FINAL Z I am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee , Signature PLUMBING PERMIT ISSUING FEE$ c [7C 7�r ❑ TOTAL FEEy SINGLE FAMILY Plan check applicant y'Ei` "CS TJ t�/ r r HOME OWNER-BUILDER DECLARATION Name !-;:+:t .g I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address(pp, ((��(� SQ 'f~ 1 Code): _., ❑ City L de Tel. No (p I "�� i f j L#'! I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business ;TATA!tyL m � and Professions Code). , —e_31 E_ CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the }i(y114 Ut ,ij I performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name ' 10 x is 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 Plumbi , and hereby authorize L=::�_� reseof is -ounty to a upon the above-mentioned pe io purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE igig/,-L- Slgnature of Permittee Date