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Home My Public Portal About5016 GLICKMAN AVE_Plumbing__ DRKERS' 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 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 5016 Glickman Ave. department.P tion de ABPP INC. / NUMBER FIXTURE OR ITEM @ FEE p a LOCALITY Temple City Date Appp4anYreSS1Ve Plumbing 3 WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' Z BATH TUB CROSS ST. Lower Azusa Rd. COMPENSATION INSURANCE SHOWER OWNER Texton Construction (This section need not be completed if the work involved by MAIL 1103 S. Sari Gabriel Blvd. #H the permit Is for one hundred dollars ($100)or loss.) LAVATORY d' ADDRESS I certify that in the performance of the work for which this If permit is issued, I shall not employ any person In any manner SINK CITY San Gabriel TEL.NO. 286-5691 so as to become subject to the Workers'Compensation Laws. DISHWASHER CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER ADDRESS 4257 Auction Ave. #F NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR Exemption, you should become subject to the Workers' CITY Baldwin Park TEL. NO. 962-2428 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS % s t� tri (commencing with Section 7000) of Division 3 of the Business OUTLETS OVER O _ and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL VALIDATION 0. 478794 C-36 ; DATE Z ®. License N ber Lic. Class `progressive Plbg. FINAL _ Contractor Date "" -` - I am exempt under Sec. 4j UW B.&P.C, for this reason Plan check fee Z Date: PLUMBING PERMIT ISSUING FEE$ Signature TOTAL FEE Plan check applicant SINGLE FAMILY is sj j'j HOME OWNER-BUILDER DECLARATION Name I hereby affirm that I am exempt from the Contractor's License `'vo: i'e Law for the following reason (Section 7031.5, Business and Address ' 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). 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date R'S COMPENSATION DECLARATION 20-0026 76A667A PW 989 APP ATION FOR PLUMBING PERMIT Ll 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 12 2 3 0 2?Company STATE FUND COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS�,3 DEPT.OF PUBLIC WORKS DIV. nNo. LSI Certified copy is hereby furnished. BUILDING �lY$Jf J_I FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 5016 GL I CKMAN Certified copy is filed with the county building inspection department. NUMBER FIXTURE OR ITEM @ FEE LOCALITY TEMPLE CITY Date 1 2/1 4/9-2ApplicantTEXTON CONST WATER CLOSET NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST. LOWER AZU SA COMPENSATION INSURANCE ' . ASSESSOR (This section need not be completed if the work involved by the SHOWER MAP BOOK PAGE 1 5 PARCEL 5 5 permit is for one hundred dollars($100)or less.) OWNER I certify that in the performance of the work for which this permit LAVATORYI ARTS TNrPT, DEV is issued, I shall not employ any person in any manner so as toMAIL SINK ADDRESS 601 S F IGUEROA 4650 become subject to the Workers'Compensation Laws. DISWASHER CITY LA TEL NO-2136241555 Date Applicant CLOTHES WASHER NOTICE TO APPLICANT: If, after making this Certificate of ECONTRACTOR TEXTON CONST Exemption,you should become subject to the Workers'Compensation SWIMMING POOL RECEPTOR provisions of the Labor Code, you must forthwith comply with such ADDRESS 1103 S SAN GABRIEL H provisions or this permit shall be deemed revoked. LAWN SPRINKLER SYSTEM LICENSED CONTRACTORS DECLARATION CITY TEL.NO-8182866090 I hereby affirm that I am licensed under provisions of Chapter 9 WATER HEATER SAN GABRIEL (commencing with Section 7000) of Division 3o the Business and STATE LIC.GAS SYSTEM OUTLETS LICENSE NO. 570978 CLASS B 0 Professions Code, and my license is in full force and effect. U OUTLETS OVER DISTRICT NPROCESSED BY 0 5 PER SYSTEM License Number 5 7 n 9 718 Lic.Class B FINAL ♦♦ VALIDATION LU Date Contractor TEXTON CONT 12/14/92 DATE ` /r El FINAL I am exempt under Sec. BY B.&P.C.for this reason Plan check fee 001.�� Signature Date: PLUMBING PERMIT ISSUING FEE$ ❑ TOTAL FEE SINGLE FAMILY Plan check applicant _— HOME'OWNER-BUILDER DECLARATION Name STARTS DEV - I hereby affirm that I am exempt from the Contractor's License Law _•`.: :3 - forthe following reason (Section 7031.5, Business and Professions Address 601 S F I GUEROA 4650 Code): City LA Tel.No21 3 6 2 41 5 5 5 I_rl- . 1, as owner of the property,will do the work and the structure irte: . is not intended or offered for sale (Section 7044, Business t" -' and Professions Code). , - �9 30 CONSTRUCTION LENDING AGENCY L•3 eLL•,: • 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, 4; bs(ryN -f Civ.C.) Lender's NameILi_if f—'•_it it`1 2 i I �t Lender's Address '-`i ' int-,t- I certify that I have read this application and state that the above ' information is correct. I agree t�ffimbing, comply with all County ordinances and State laws regulating and hereby authorize represent ef this Cou yenter upon he abo e-mentioned pro -for cion pur s. • SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee ate