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Home My Public Portal About4956 GLICKMAN AVE_Plumbing__ ORKERS'COMPENSATION DECLARATION AI .ICATION 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 olcy 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 4956 ' Glickman AVe tion department. NUMBER FIXTURE OR ITEM @ FEE ABPP INC. / LOCALITY Temple City Date App1gp9gressiye Plumbing WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' -7 BATH TUB 0 CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE i r SHOWER OWNER Texton Construction (This section need not be completed if the work involved by c7 the permit is for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS Blvd.I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY San Gabriel TEL. No. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER / � CONTRACTOR Progressive Plumbincf Date Applicant CLOTHES WASHERADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F ec you, Exem tionshould become subject to the Workers' SWIMMING POOL RECEPTOR Exemption, y I CITY Baldwin Park TEL NO. 962-2428 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER f LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER d and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION ►L� �� License Number 478794 Lic. Class C-36 DATE 0,� Progressive Plbg. G2 (' FINAL Contractor Date BY ❑ I am exempt under Sec. W' B.&P.C. for this reason lila Plan.check fee U) Date: PLUMBING PERMIT ISSUING FEE$ Signature ' TOTAL FEE D� 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 --••6 - -_• - 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 forthe performance of the work for which this permit is issued (Sec. 3097, Civ. C.). '..f-J-1 •�F-°lei„' Lender's Name' On :tr 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-mention 'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE • Signature of Permittee Date ER'S COMPENSATION DECLARATION 20-0026 DPW 9I 89 APF ',ATION FOR PLUMBING PERMIT 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.) , STS COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. Policy No.' 3� Company ru N� A/21- ❑ Certified copy is hereby furnished. F� FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY--TC-KA Date �" _ 1-o, -Applicant—) eXTUry GO�� 1 WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LrflL �� -l�'�ny COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK �� PAGE S PARCEL'�,_>S permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit MAIL LAVATORY is issued, I shall not employ any person in any manner so as to SINK ADDRESS L4 la- become subject to the Workers'Compensation Laws. 1 S DISWASHER CITY (`46, TEL.NO.2,I2 t.0,`�t5T-1 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 5,4�, L provisions or this permit shall be deemed revoked. ' LAWN SPRINKLER SYSTEM S LICENSED CONTRACTORS DECLARATION CITYCL TEL.NO.�� bp I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER q (commencing with Section 7000)of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO.'5�0 Y_1Z CLASS L) Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICTNO. PROCESSED BY cc 5 PER SYSTEM License Number 4570Fc�11IR Lic.Class FINAL }}} DATE ^� VALIDATION W -M 6/ /z. liZ C. Contractor I-I�'i'O 0' �l4 ST Date G 01) F-1FINAL — Z I am exempt under Sec. BY B.&P.C.for this reason Plan check fee Date: Signature PLUMBING PERMIT ISSUING FEE$ a2 V6 ❑ TOTAL FEE ( el- (� Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name `s-Ti/4q=,S PC— / I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Address 60 tj r—bv(W=A10A EZ 7 Code): �.L.r ❑ City Tel.No`�?j(02l 1 ire '' ` I,as owner of the property,will do the work and the structure 1 is not intended or offered for sale (Section 7044, Business / , j I T;3) 3 - 30 and Professions Code). "_ i 39.33 5 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Hi)iG` performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name 0 t I-:00_11 I'o��: 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 re lating.Plumb* , and hereby authorize representatives o is Cou ty to a to upon the above-mentioned pr pert r in n p es. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date