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Home My Public Portal About4962 GLICKMAN AVE_Plumbing__ DRKERS'COMPENSATION DECLARATION Al .ICAT16N FOR PLUMBING PERMIT �7 I here 'irm that I have a certificate of consent to self 20-0026 DPW 6/87 I� 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 a Certified copy is filed with the county building inspec- ADDRESS 4962 Glickman Ave. tion department. ABPA INC. NUMBER FIXTURE OR ITEM @ FEE P p � LOCALITY Temple City Date Appli4Or�t�gr25Slye Plumbing WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATH TUB CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE o OWNER Texton Construction (This section need not be completed If the work involved by SHOWER the permit is'for one hundred dollars($100)or less.) LAVATORY MAIL ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is Issued, I shall not employ any person in any manner SINK CITY San Gabriel TEL. No. 286-5691 so as to become subject to the Workers'Compensation Laws. l DISHWASHER CONTRACTOR PrOgrE?SS1Ve Plumbing Date Applicant CLOTHES WASHER s ADDRESS 4257 Auction Ave. #F NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY Baldwin Park TEL. NO. 962-24.28 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER ICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEMOUTLETS I gyri (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER - and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION License Number 478794 Lic. Class C-36 Z ,G ® DATEZ" Z - 0' Progressive Plbg. TIAL Contractor Date BY - I am exempt under Sec. W B.&P.C. for this reason Plan,check fee Date: a PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE - 1 Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name ;)-E•l•ls i. ,,r`M<<f;.; I hereby affirm that I am exempt from the Contractor's License Address -_ _- Law for the following reason (Section 7031.5, Business and 1 '� 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 Opp, 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-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signat de—To e mittee Date V R'S COMPENSATION DECLARATION 20-0026,A PW9�89 APP :ATION FOR PLUMBING PERMIT I hereby affir I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof(Sec.3800 Lab.C.) Policy No. 1223029 Company STATE FUND 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 Certified copy is filed with the county building inspection ADDRESS 4962 GLI CKMAN department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Date 12/14/92Applicant TEXTON CONST TEMPLE CITY i WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK 8585 PAGE 15 1PARCEL 55 permit is for one hundred dollars($100)or less.) LAVATORY OWNER STARTS DEV I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to SINK MAIL ADDRESS 601 S FI GUEROA 4650 become subject to the Workers'Compensation Laws. DISWASHER CITY TEL.NO. T-A21 36241 5 5 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of TEXTON CONST Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such I NADDRESS 1103 S SAN GABRIEL H provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION / CIN SAN GABRI EL TEL'NO-81828660 0 >' I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER 0. (commencing with Section 7000) of Division 3 of the Business and STATE LIC. O Professions Code,and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 570978 CLASS B U OUTLETS OVER DISTRICT NO. PROCESSED BY 5 PER SYSTEM License Number 570978 Lic.Class B �� V FINAL VALIDATION W Contractor TEXTON CONST Date 12/14/92 DATE Z—22- I Z- G. ❑ FINAL Z I am exempt under Sec. By B.&P.C.for this reason Date: Plan check fee Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE lf' � SINGLE FAMILY Plan check applicant c HOME OWNER-BUILDER DECLARATION Name TA DEV. I hereby affirm that I am exempt from the Contractor's License Law ° for the following reason (Section 7031.5, Business and Professions Address 601 S FI GUEROA 4650 3_i, 1- +_ i Code): `'`• ElCity LA Tel.No. 2136241 55E 7 T-,E:iC I,as owner of the property,will do the work and the structure 1 1' is not intended or offered for sale (Section 7044, Businesso and Professions Code). 35 9 30 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the C °ht''' Ili! performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name ' 13.IC s• s.; 1 Lender's Address I certify that I have read this application and ate tF at the above , information is correct. I agree to comf ly wit all Coyynty ordinances and State la�to g Plu !Sing, nd hefeby authorize representativenty to nter pon�he�abov mentioned prop r eo / SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date