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Home My Public Portal About5006 GLICKMAN AVE_Plumbing__ ORKERS'COMPENSATION DECLARATION A ■KATION 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 cy No 3641-92 company State Fund Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ❑X Certified copy is filed with the county building inspec- ADDRESS 5006 Glickman Ave. tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEE -LOCALITY Temple City Date ApplPWn4gressive Plumbing WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' 'Z BATH TUB O CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE OWNER Texton Construction (This section need not be completed if the work involved by SHOWER MAIL the permit is for one hundred dollars ($100)or less.) LAVATORY rj� ADDRESS 1103 S. San Gabriel Blvd. #H I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner SINK IL4, S CITY San Gabriel TEL. NO. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR progressive Plumbing Date Applicant CLOTHES WASHER ADDRESS 4257 Auction Ave., #F NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' . CITY TEL. NO. Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM Baldwin Park 962-2428 with comply with such provisions or this permit shall be IT.Tr LIC. deemed revoked. WATER HEATER LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER �i� and Professions Code,and my license is in full force and effect. 5 PER SYSTEM 2FINAL VALIDATION , ISI � DATE License Number 478794 Lic. Class O : Progressive Plbg. FINAL U Contractor Date BY 0 ❑ 1 am exempt under Sec. (~jl B.&P.C. for this reason i0.1 Plan check fee tn. Date: Z' PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE �p�e �' ( t_;,;[ G T SINGLE FAMILY Plan check applicant HOME OWNER-BUILDER DECLARATION Name 1 .^ I hereby affirm that I am exempt from the Contractor's License Address Law for the following reason (Section 7031.5, Business and • -'' _ice = •:_,�_ 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). polo CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending agency for -- - •-- -• 'i 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-mentioned'property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date F TS COMPENSATION DECLARATION 20-0026 76A667A PW 9/89 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 1223029 Company ff�t STATE FUND COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT.OF PUBLIC WORKS DIV. P❑ No. Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING Certified copy is filed with the county building inspection ADDRESS 5006 GL I CKAMN department. NUMBER FIXTURE OR ITEM @ FEE � LOCALITY TEMPLE CITY Date 12/1 4/9 2p plicant TEXTON CONST WATER CLOSET cROSSST. LOWER AZUSA CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB COMPENSATION INSURANCE ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK 8585 PAGE 1 5 PARCEL 55 permit is for one hundred dollars($100)or less.) OWNER STARTS DEV. I certify that in the performance of the work for which this permit LAVATORY is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS 601 S FIGUEROA 4650 become subject to the Workers'Compensation Laws. DISWASHER CITY LA TEL. - 2136241555 5 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of TEXTON ,CONST. Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ' ADDRESS 1 1 0 3 S SAN GABRIEL H provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION / CIN SAN GABRI ETLL•No- 8182866090 9' I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER (commencing with Section 7000) of Division 3 of the Business and STATE LIC. Professions Code, and my license is in full force and effect. GAS SYSTEM OUTLETS LICENSE NO. 570978 CLASS B V I OUTLETS OVER DISTRICT NO. PROCESSED BY M: 5 PER SYSTEM License Number 570978 Lia Class B U FINAL VALIDATION W TEXTON -CONST 12/14/92 DATE CZ�-(7 CL Contractor Date ❑ I am exempt under Sec. FII AL Z B-.&P.C.for this reason Date: Plan check fee , Signature PLUMBING PERMIT ISSUING FEE$ b- ❑ TOTAL FEE .` 0 Plan check applicant SINGLE FAMILY 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 FIGUEROA 4650 - --: - Code): City LA Tel.No21 . ._,_3 ❑ 3 6 2 41 5 5 5 Y ;. I,as owner of the property,will do the work and the structure � ;I�-•�i'-` is not intended or offered for sale (Section 7044, Business ^•n and Professions Code). s - - L 39 CONSTRUCTION LENDING AGENCY .30 I hereby affirm that there is a construction lending agency for theI'n5 rIN (-- performance of the work for which this permit is issued (Sec. 3097, �` 'fit' Civ.C.) Lender's Name -+s•w •JI_`_— - Lender's Address 704 i - 10:4.S I certify that I haver d this applicati nd state that the above , information is corre I a ree to com ly ith all.County ordinances and State ws egulat)ng Plum in , and hereb authorize repress Ives this 'u ty to en upon the bo -mentioned pr ty for' s'eFtJdn, se �jJ I�.\ �•�' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date 1 (/