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Home My Public Portal About4958 GLICKMAN AVE_Plumbing__ T ORKERS'COMPENSATION DECLARATION A LICATION FOR PLUMBING PERMIT I here 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, Lob. 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 4958 Glickman Ave. tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City ' Date Appli Eggressive Pl2glbLng WATER CLOSET NEAREST Z ' CROSS ST, Lower Azusa Rd. BATH TUB CERTIFICATE OF EXEMPTION FROM WORKERS' /O COMPENSATION INSURANCE f SHOWERs— OWNER TextOh Construction (This section need not be completed if the work Involved by MAIL the permit Is for one hundred dollars ($100)or lass.) LAVATORY ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this' permit is issued, I shall not employ any person In any manner SINK CITY San Gabriel TEL, NO. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER ADDRESS 4257 Auction Ave. #F NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITYTEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Baldwin Park 962-2428 with comply with such provisions or this permit shall be STATE 478794LIC C-36 deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION / DISTRICTPROCESSED B i hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business 1 OUTLETS OVER and Professions Code,and m license is in full force and effect. / 5 PER SYSTEM ?; Y FINAL VALIDATION 478794 C-36 DATE ®, License Number Lic. Class U. Progressive Plbg. v2 � FINAL Contractor Date BY -•— I am exempt under Sec. v _W B.BP.C. for this reason Date: Plan check fee PLUMBING PERMIT ISSUING FEE$ �� -Ur — Signature TOTAL FEE Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address 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 repre°sentatives of this County to enter upon the above-mention property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of. Permittee Date 1 :R'S COMPENSATION DECLARATION 6 DPW 9/69 APP ;ATION FOR PLUMBING PERMIT 76A66 I hereby affil ! 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.) 1223029 Company STATE FUND COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS��/ DEPT.OF PUBLIC WORKS DIV. Policy No. UILDING Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDR SS 4958 GL I CKMAN 5a Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TEMPLE CITY Date 1 2/1 4/9?pplicant TEXTON CONST WATER CLOSET NEAREST LOWER AZUSA CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. COMPENSATION INSURANCE BATH TUBASS (This section need not be completed if the work involved by the ISHOWER MAPEBOOK 8585 PAGE 15 PARCEL 5 5 permit is for one hundred dollars($100)or less.) LAVATORY OWNER STARTS DEV. I certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS 601 S FIGUEROA 4650 become subject to the Workers'Compensation Laws. DISWASHER CITY LA TEL NO.213 6 2 415 5 5 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of TEXTON CONSTRUCTION Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 1103 S SAN GABRIEL H provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CIN SAN GABRI EL TEL.NO.81 8 2 8 6 6 O O �- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER IZ (commencing with Section 7000) of Division 3 of the Business and STATE GAS SYSTEM OUTLETS LICENSE NO. 5 7 0 9 7 8 CLASS B 0 Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY Cc 5 PER SYSTEM ��CJ License Number 570978 Lic.Class B V TEXTON CONST 12-14-92 FINAL VALIDATION w DATE � -' J a Contractor Date !/ Cf1 INAL Z ❑ I am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee PLUMBING PERMIT ISSUING FEE$ 1:W Signature , ❑ TOTAL FEE Plan check applicant ` SINGLE FAMILY 'S HOME OWNER-BUILDER DECLARATION Name STARTS INTL DEV I hereby affirm that I am exempt from the Contractor's License Laws t'I for the following reason (Section 7031.5, Business and Professions Address 601 S FIGUEROA 4650 jyif Code): ❑ CityLp, Tel.No. 2136241554 I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business 6, ;s_CI r 6—, ='ISL o LJ and Professions Code). res is CONSTRUCTION LENDING AGENCY -• °- I hereby affirm that there is a construction lending agency for the •HAINt3G performance of the work for which this permit is issued (Sec. 3097, Civ.C.) Lender's Name 7, Arlt i Lender's Address I certify that I have read this application and state that the above , information is correct. I agree to co ply with all County ordinances LrepresentgtWes tate laws r ti g PI bi g, and hereby authorize t '/C unty o g er upon the above-mentioned for' do urpos s/ SEE REVERSE FOR EXPLANATORY LANGUAGE G )12- Signature of Permittee Date