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HomeMy Public PortalAbout5002 GLICKMAN AVE_Plumbing__ ORKERS'COMPENSATION DECLARATION A• .ICATION FOR PLUMBING PERMIT I her, '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 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 5002 Glickman Ave. tion department. ABPP INC. � NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Date AppIlgon E SS1Ve Plumbing 3 WATER CLOSET NEAREST Lower Azusa Rd. CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB D CROSS ST. COMPENSATION INSURANCE SHOWER OWNER Texton Construction (This section need not be completed If the work Involved by MAIL the permit Is for one hundred dollars ($100)or less.) LAVATORY ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK CITY San Gabriel TEL. NO. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Progressive Plumbin Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CITY Baldwin Park TEL. No. 962-2428 with comply with such provisions or this permit shall be STATE LIC. / deemed revoked. WATER HEATER CENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS r (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER s� v and Professions Code,and m license is in full force and effect. 5 PER SYSTEM Y FINAL VALIDATION 478794C-36 Z D.5- © DATE Z--2/ License Number Lic. Class �' Progressive Plbg. FINAL Contractor Date B �C ❑ I am exempt under Sec. B.BP.C. for this reason Plan check fee ® ., U) Date: _-. PLUMBING PERMIT ISSUING FEE$ i �` Signature _ TOTAL FEE Plan check applicant _ SINGLE FAMILY 26 "_ ~-w, HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address ;; -Ar`` -M s);i Professions Code): City Tel. No. ❑ 1, 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-mentione 'property for inspection purposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE ~I ::f Signat a of Permittee Date f I - V1 I'S COMPENSATION DECLARATIof consent to 76A666DPW9/89 APPI ATION FOR PLUMBING PERMIT 76A667A I hereby affiri 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 ,7 DEPT.OF PUBLIC WORKS DIV. ❑q Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 5002 GLI CKMAN Certified copy is filed with the county building inspection ADDRESS department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TEMPEE CITY Date 12/14/9?Applicant TEXTON CONST WATER CLOSET RO . ST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CSSS LOWER AZUSA COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK 8585 PAGE 15 1 PARCEL 5 5 permit is for one hundred dollars($100)or less.) -LAVATORY OWNER STARTS DEV. - I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as toSINK MAIL become subject to the Workers'Compensation Laws. ADDRESS 601 q FIGUEROA 4650 DISWASHER CITY LA . TEL.NO.21 36241555 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR TEXTON CONST. Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 1103 S SAN GABRIEL H provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION / CITY SAN GABRIELTEL.NO. 818286610 I hereby affirm that I am licensCL ed under provisions of Chapter 9 WATER HEATER STATE LIC. 0 (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 570978 CLASS B V Professions Code,and my license is in full force and effect. OUTLETS OVER DISTRICT NO. PROCESSED BY cc 5 PER SYSTEM .r J License Number -570978 Lic.Class B FINAL VALIDATION W TEXTON CONST 12/1 /92 DATE t��17 `� a Contractor Date, Cl) ❑ I am exempt under Sec. BY AL Z B.&P.C.for this reason Date: Plan check fee , "Signature PLUMBING PERMIT ISSUING FEE$ ' ❑ TOTAL FEE SINGLE FAMILY Plan check applicant ' 5 HOME OWNER-BUILDER DECLARATION Name STARTS 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 ` Code): -:. fa, - ❑ city LA Tel.No. 21 36241515 - C,tr- 1,as owner of the property,will do the work and the structure I i-i 3'= is not intended or offered for sale (Section 7044, Business , Ti"j i(+{i ` 30and Professions Code). 3 CONSTRUCTION LENDING AGENCY - I hereby affirm that there is a construction lending agency for the t•i is ism z�i performance of the work for which this permit is issued (Sec. 3097, Civ. C.) _ r _ Lender's Name - �-• •- Lender's Address 't I certify that I have read this application and ate tat the above , information is correct. I agree to comply wilt it all Courity ordinances and State laws reg 'ng Plumbing,�enter ndieby authorize representatives of; Coufre a ove- entioned proper i action pu, SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date