The URL can be used to link to this page

Home My Public Portal About5010 GLICKMAN AVE_Plumbing__ ORKERS'COMPENSATION DECLARATION A .ICATION FOR PLUMBING PERMIT I here 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 5010 ' Glickman Ave. tion department. ABPP INC. NUMBER FIXTURE OR ITEM @ FEE LOCALITY Temple City Progressive Plumbing WATER CLOSET Date Applicant NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATHTUB CROSS ST. Lower 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 S1o0 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 TEL.NO. 286—.55691 so as to become subject to the Workers'Compensation Laws. DISHWASHER f CONTRACTORPYogressive Plumbing Date Applicant CLOTHES WASHER ADDRESS 4257 Auction Ave. #F NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR 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 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 t� and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 478794 C-36 rf O DATE �� j ;�� License Number Lic. Class Progressive Plbg. FINAL Contractor Date BY ❑ o� I am exempt under Sec. (� B.BP.C. for this reason 0-1 Plan check fee V) :.; _ .�__._. - r � Date: . PLUMBING PERMIT ISSUING FEE$ - Signature ,7 TOTAL FEE j Plan check applicant SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License j"s:h ,i- j Law for the following reason (Section 7031.5, Business and Address •;' 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-mentio d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee' Date V R'S COMPENSATION DECLARATION 6DPW9/69 APP ATION FOR PLUMBING PERMIT 76A66 I hereby affir 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.) Policy No. 12 2 3 0 2 9 Company STATE FUND COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS DEPT. OF PUBLIC WORKS DIV. AY Certified copy is hereby furnished. FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING ADDRESS 5010 GL I CKMAN Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TEMPLE CITY Date 12/1 4/94plicant TEXTON CONST WATER CLOSET I NEAREST 6 CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. LOWER AZUSA COMPENSATION INSURANCE BATH TUBIASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK 8585 PAGE 1 5 PARCELS 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 MAIL is issued, I shall not employ any person in any manner so as to SINK ADDRESS 601 S FIGUEROA 4650 become subject to the Workers'Compensation Laws. olswnsHER CITY LA TEL'NO'213 6 2 415.5 5 Date Applicant CLOTHES WASHER CONTRACTOR NOTICE TO APPLICANT: If, after making this Certificate of TEXTON CO Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR ADDRESS 1103 S SAN GABREIL provisions of the Labor Cade, you must forthwith comply with such r provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY SAN GABRI EL TEL.No.81 8 2 8 6 6 0 0 >- I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER CL STATE LIC. 0 (commencing with Section 7000) of Division 3 of the Business and GAS SYSTEM OUTLETS LICENSE NO. 570978 CLASS B Professions Code,and my license is in full force and effect. V OUTLETS OVER DISTRICT NO. PROCESSED BY O 5 PER SYSTEM License Number 570978 Lic.Class B FINAL / VALIDATION W contractor TEXTON CONST Date 1 2�$4 /9 2 DATE �Z.l N ❑ FINAL 111 Z I am exempt under Sec. BY BAP.C.for this reason Date: Plan check fee ► Signature PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE � () Plan check applicant =� SINGLE FAMILY » HOMEOWNER-BUILDER DECLARATION Name STARTS DEV. "'� a 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 33r,17 —, i Code): �-f » ■= FJ 1, LA Tel.No. 213 6 2 415 5 _ EMS I,as owner of the property,will do the work and the structure -1 is not intended or offered for sale (Section 7044, Business , -•ta and Professions Code). CE CONSTRUCTION LENDING AGENCY CHECK #.I I hereby affirm that there is a construction lending agency for the "I Ir-- li»I performance of the work for which this permit is issued (Sec. 3097, `'_ Civ.C.) Lender's Name k Lender's Address A-139 1610'.44 I certify that I have read this application and state that the above , information is correct�I agree t omply with all County ordinances and Sta aw� gulatin tubing, and hereby authorize rep entatil 2 this Co t o enter upon thebove entioned operty fo spection p es. 1 �7� _ SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date