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Home My Public Portal About4952 GLICKMAN AVE_Plumbing__ ORKERS'COMPENSATION DECLARATION A .KATION FOR PLUMING PERMIT I her, '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 4952 Glickmaii,Ave. tion department. ABPP INC. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Prpgressive Plumbing WATER CLOSET Temple Cit Date Appligan NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATHTUB Gf U CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE l SHOWER 761 OWNER Texton Construction (This section need not be completed If the work Involved by MAIL the permit is for one hundred dollars ($100)or less.) , LAVATORY ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK L!J'CITYSan Gabriel TEL. NO. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR ADDRESS Compensation provisions of the Labor Code, you must forth- CITY Baldwin Park TEL' NO. 962-2428 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER f1LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION / DISTRICT NO. O PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS n C7 yv� (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER fi Q G and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION R�.� 478794 C-36 DATE Po,.C License Number Lic. Class ��,�� Q. Progressive Plbg. �2i Q FINAL Contractor Date BY 0. I am exempt under Sec. � B.&P.C. for this reason a�' Plan check fee z Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant _ SINGLE FAMILY r_ z 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 7 rjy Professions Code): City Tel. No. ' ❑ r;c'-` s I, as owner of the property, will do the work and the i structure is 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 ed property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �..Ja- GjL Signature of Permittee Date ER'S COMPENSATION DECLARATION 20-0026 9/89 APP "FATION FOR PLUMBING PERMIT ll 76A66 I hereby off It 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.�Z� i0?�t CompanyA`�C-- Eu N2 COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Es Certified copy is filed with the county building inspection ADDRESS .4952— C U6X^^J1" department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY —re dl^,�1JE U Date Z Z Applicant��C)tf �1� WATER CLOSET NEAREST nr � a CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.L_,0 L`c COMPENSATION INSURANCE BATH TUB ASSESSOR _ (This section need not be completed if the work involved by the SHOWER MAP BOOK �j `J PAGE [: PARCEL rj permit is for one hundred dollars($100)or less.)' OWNER -r�/L—f S V I certify that in the performance of the work for which this permit LAVATORY °� �L is issued, I shall not employ any person in any manner so as to SINK MAIL ADDRESSj(� l 5 (VUE/LQ/t, p�l� become subject to the Workers'Compensation Laws. DISWASHER CITY L'/0 j rn,),) u S TEL.NO.217j[a�,l�>C'Lj Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS /a�?J 5Atj 6 AGnda� provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM ��tt LICENSED CONTRACTORS DECLARATION / CITY CS N LA(2 TEL.NO.&�j I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER IL STATE LIC. 0 (commencing with Section 7000) of Division 3 of the Business and LICENSE NO.� -��p� CLASS 61 Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS OUTLETS OVER DISTRICT NO. 5- PROCESSED BY tZ 5 PER SYSTEM Sr ap � C C U �'✓1y l2? License NumberLic.Class FINAL VALIDATION W DATE �LkiC�h+ to— El d Q Contractor L'o�9� Date �Z'I y r�— r!� FINAL I am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee 010. PLUMBING PERMIT ISSUING FEE$ �[�G Signature ❑ TOTAL FEE �l o SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Namey-(S I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address l �l(��y�r(�p� 6_f0 f yr •s_li Code): ��11,� ❑ City L& Tel.No. f S FYI' ! T I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business , s i TAl` 39 30 and Professions Code). s'SsC. _ i( .I;_.. �`"r a CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the w• i _L aii performance of the work for which this permit is issued(Sec. 3097, Civ.C.) Lender's Name Hr if l.° ` Lender's Address I certify that I have read this application and state that the above , information is correct. I agree to comp with all County ordinances and State laws regulating Plu i , and hereby authorize representatives his C unty to nt upon the above-mentioned grope for' tion ses. SEE REVERSE FOR EXPLANATORY LANGUAGE L Sig ature of Permittee Date