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Home My Public Portal About4960 GLICKMAN AVE_Plumbing__ IRKERS'COMPENSATION DECLARATION AF ICATION FOR PLUMBING PERMIT I herel rm 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. BUILDING FOR APPLICANT TO FILL IN(PRINT OR TYPE) 4960 Glickman Ave. 17XCertified copy is filed with the county building inspec- ADDRESS tion department. ABpp INC. NNUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Date ApplzO�gressive PlumbingWATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB �� CROSS 5T. Lower Azusa Rd. COMPENSATION INSURANCE /SHOWER OWNER Texton Construction (This section need not be completed if the work involved by MAIL the permit it for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1103 S. San Gabriel Blvd. #h I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINKA4 CITY San Gabriel TEL. NO. 286-5691 so as to become subject to the Workers'Compensation Laws, / DISHWASHER CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR 4257 Auction Exemption, you should become subject to the Workers' CITY Compensation provisions of the Labor Code, you must forth- Baldwin Park TEL.NO. 962-2428 LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER `— LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION J DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS ry (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER D and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 478794C-36 -�z- 6� �2 /0 DATE �Z.ZZ License Number Lic. Class i�a_,I„ 0. Progressive Plbg. FINAL _ Contractor Date BY ❑ I am exempt under Sec. WJ B.&P.C. for this reasonPlan check fee t "{I r''`" Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY i;;=€'is".._;";l__.I ;'`F,..:'•< 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. ❑ 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 representatives of this County to enter upon the above-menti o ed'property for inspection purposes. - SEE REVERSE FOR EXPLANATORY LANGUAGE --�o J Signature of Permittee Date I :R'S COMPENSATION DECLARATION 20-0026 DPW 9/89 APP :ATION FOR PLUMBING PERMIT I hereby affi t I have a certificate of consent to self insure, 76A667A , or a certificate of Worker's Compensation Insurance, or a certified colicy No. �py thereof(Sec.3800 Lab.C.) Po 1 Company /2 2 3 0 2 9 STATE FUND COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS A /, DEPT.OF PUBLIC WORKS DIV. ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS 4960 GL I CKMAN department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY Date 1 2/1 4/9 applicant TEXTON CONST WATER CLOSET TEMPLE CITY CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSSST. LOWER AZUSA COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK 8585 IPAGE 15 1 PARCEL, 55 permit is for one hundred dollars($100)or less.) LAVATORY OWNER STARTS DEV. I certify that in the performance of the work for which this permit MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS 601 S FIGUEROA 4650 become subject to the Workers' Compensation Laws. DISWASHER CITY LA TEL'N021 3 6 2 415 6 5 Date Applicant CLOTHES WASHER CONTRACTOR TEXTON CONST. NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 1103 S SAN GABRIEL H provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION 1 CITY SAN GABRI ELTEL.No- 8182866C90 9- I hereby affirm that I am licensed under,provisions of Chapter 9 WATER HEATER d (commencing with Section 7000) of Division 3 of the Business and STATE LIC. Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 570978 CLASS B V " OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM License Number 5 7 0 9 7 8 Lic.Class B FINAL VALIDATION W TEXTON CONST 12/14/92 DATE ��_�� CL Contractor Date CO INAL Z El am exempt under Sec. BY B.&P.C.for this reason Date: Plan check fee ' Signature PLUMBING PERMIT ISSUING FEE$ F-1 75- TOTAL FEE SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name ;"T a I hereby affirm that I am exempt from the Contractor's License Law STARTS DEV. for the following reason (Section 7031.5, Business and Professions Address 601 S FIGUERUA 46bO Code): - _ L•_ Tel.No. 21 3 6 2 41 5 5 f x a I,as owner of the property,will do the work and the structure El 1, is not intended or offered for sale (Section 7044, Business ? 39 :30 and Professions Code). , - o,:v CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the CHANGE ,(?� performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name "r!L z i °Eat{r Lender's Address I certify that I have read this application and state that the above , information is correct. I agree to com 'th all County ordinances and State laws regulate Plu ing and hereby authorize representatives of this ty ,ente upon the above- 'entioned propert rfnspe n urpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date