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Home My Public Portal About5000 GLICKMAN AVE_Plumbing__ )RKERS'COMPENSATION DECLARATION Al ,ICATION FOR PLUMBING PERMIT I here irm that I have a certificate of consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers' Compensation Insurance, 76A667A lul or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 0 cy No. 3641-92 Company State Fund Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING LX.I Certified copy is filed with the county building inspec- ADDRESS 50Q0 Gl]Cklnari Ave. r� tion department. ABPP INC:. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Date Applic8Xogressiye Plumbing 3 WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 'L BATH TUB CROSS ST. IAWer Azusa Rd. COMPENSATION INSURANCE OWNER Texton Construction (This section need not be completed if the work involved by SHOWER the permit is for one hundred dollars $loo or less. MAIL 1103 S. San Gabriel Blvd. #H p ( ) ) LAVATORY ADDRESS I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY San Gabriel- so "°• 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER co"rRAcroR Prociressive Plumbin Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR CITYTEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Baldwin Park 962-2428 with comply with such provisions or this permit shall be STATE 478794 LIC. C-36 deemed revoked. WATER HEATER LICENSE NO. CLASS LICENSED CONTRACTORS DECLARATION DISTRICT No, PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM d FINAL VALIDATION License Number 478794 Lic. Class C-36 C, Aj DATE Z;, Progressive Plbg. FINAL Contractor Date BYtan a ❑ lam exempt under Sec. B.&P.C. for this reason _ ~- Ki i ' Plan check fee z Date: y ,®. PLUMBING PERMIT ISSUING FEE$ L t.l?>;� _� _ Signature TOTAL FEE �j ~�_„."; _,__ ,_•• Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name 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. r :•_^lr ❑ 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-mention d'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE • > 1 Signature of P rmittee Date DECLARATI V TSCOMPENSATION of consent to 76A666DPW9/89 APP ATION FOR PLUMBING PERMIT 76A667A 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.) STATE FUND 1 223029 SEX '®lei=�®gda�= COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. PolicyNo. Company s ❑ 4� Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS 5000 GL I CKMAN 93 Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE 12/14/9 2 TEXTON CONST LOCALITY TEMPLE CITY Date Applicant WATER.CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LOWER AZUSA COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE PARCEL 5 permit is for one hundred dollars($100)or less.) LAVATORY OWNER STARTS DEV. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to SINK MAIL ADDRESS become subject to the Workers'Compensation Laws. 6 1 FIGUEROA 46 50 DISWASHER CITY LA TEL.NO-2136241555 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of TEXTON CONST. Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS provisions or this permit shall be deemed revoked. r LAWN'SPRINKLER SYSTEM A/ LICENSED CONTRACTORS DECLARATION r CITY TEL.NO. WATER HEATER SAN GABRI EL 81 8 2 8 6 6 0 0 I hereby affirm that I am licensed under provisions of Chapter 9 STATE LIC. (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 0 9 7 8 CLASSB U Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY / [[ 5 PER SYSTEM sl� �." ✓ d License Number 5 7 0 9 7 8 Lic.Class B L TEXTON CONST 12/14/92 DATe Lam/ VALIDATION a- Contractor Date fn ❑ I am exempt under Sec. FINAL ZBY B.&P.C.for this reason Date: Plan check fee , - PLUMBING PERMIT ISSUING FEE$ Signature �L ❑ TOTAL FEE �. -3,0 , Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name STARTS DEV. 1 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 FIGUEROA 4650 _ Code): "� ❑ City 1, Tel.No-21 3 6 2.41 5 5 5 s L I, as owner of the property,will do the work and the structure is not intended or offered for sale Section 7044, Business — T0' ''' 39 - 30 and Professions Code). _ CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending agency for the {:Y4�'•3 .sem°I° performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name -0;: ..y Lender's Address I certify that I have read this application d state that the above , information is correct. agree,o comp w'h all County ordinances and State laws r ulatin Plum ng and hereby authorize repres alive this minty to to upon th ab ve-mentioned erty f specti urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 1 Signature of Permittee Date