HomeMy Public PortalAbout5004 GLICKMAN AVE_Plumbing__ V R'S COMPENSATION DECLARATION 20-0026 DPW,9/89 APP ATION FOR PLUMBING PERMIT
76A66
I hereby affix 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.)
�y No. 1223029 Company STATE FUND COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV.
PoliCertified copy is hereby furnished. �iOrn/y!C?N
FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING 5004 GL I CKMAN
Certified copy is filed with the county building inspection ADDRESS
department. NUMBER FIXTURE OR ITEM Qo FEE LOCALITY TEMPLE CITY
Date 12/14/9 4plicant TEXTON CONST WATER CLOSET
NEAREST LOWER AZUSA
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST.
COMPENSATION INSURANCE BATH TUB ASSESSOR
(This section need not be completed if the work involved by the SHOWER MAP BOOK 8585 PAGE 15 PARCEL 55
permit is for one hundred dollars($100)or less.) OWNER STARTS DEV.
I certify that in the performance of the work for which this permit LAVATORY
is issued, I shall not employ any person in any manner so as toMAIL
SINK ADDRESS 60x1 S. FIGUEROA 4650
become subject to the Workers'Compensation Laws. .
DISWASHER CITY LA TEL.NO. 213 6241 5
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after making this Certificate of CONTRACTOR
TEXTON CONST,
Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR
provisions of the Labor`Code, you must forthwith comply with such ADDRESS 1103 S SAN GABRIEL H
provisions or this permit shall be deemed revoked. / LAWN SPRINKLER SYSTEM
LICENSED CONTRACTORS DECLARATION CITY SAN GABREIL TEL.No.81 8'28660- 0 >
I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER Il
LIC. 0
(commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS L CET SE NO. 570978 CLASS B
Professions Code,and my license is in full force and effect.
DISTRICT O.
•
OUTLETS OVER INPROCESSED BY`yo a:
B 5 PER SYSTEM +�
License Number 570978 Lic.Class
FINAL V 0
Contractor TF.XTON CONST Date - 12/14/92 DATE VALIDATION
❑ I am exempt under Sec. BY AL
r lQ/t y
B.&P.C.for this reason
Plan check fee
Date: ,
PLUMBING PERMIT ISSUING FEEt$
Signature
❑ TOTAL FEE `L
SINGLE FAMILY Plan check applicant _F
-
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 Professions' Address 601 S FIGUEROA 4650 —,s
Code): ,
❑ City LA Tel.No-2136241555
I, as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business , `G _37 0
and Professions Code).
CONSTRUCTION LENDING AGENCY
.r 7i c vt'
I hereby affirm that there is a construction lending agency for the 3_yjA;,tGE sj=j r
performance of the work for which this permit is issued (Sec. 3097,
Civ.C.)
Lender's Name -- i ice: 14/9"
_
3 .s:•.. d—
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 ulating Plumbing, and hereby authorize
represgDtatillv his Coun t enter upon the above-mentioned
p
art y "tion pur o s. h SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date