HomeMy Public PortalAbout5343 GLICKMAN AVE_Plumbing__ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
I hereby affirm that I have a certificate of consent to self 76A667A
insure, or a certificate of Workers' Compensation Insurance, CE 817(REV. 10/81)
or a certified copy thereof (Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy Nc967370Company elden iris . service
L}r0J Certified copy is hereby furnished.
F-1Certified
APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 5343 Glickman
tion department. NUMBER FIXTURE OR ITEM Q FEE LOCALITY
Temple City
Date Jul. 6 $ApplicanWATER CLOSET l G+G Solar NEAREST
CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB CROSS ST.
COMPENSATION INSURANCE OWNER
(This section need not be completed if the work involved by SHOWER Albert an MOO
the permit is for one hundred dollars(;100)or less.) LAVATORY MAIL
ADDRESS 5343 Glickman
I certify that in the performance of the work for which this
permit is issued, I shall not employ an person in an manner SINK CITY TEL. NO
P P y vP v Tem le Cit 444-4732
so as to become subject to the Workers'Compensation Laws. DISHWASHER
CONTRACTOR G+G SOLAR
Date Applicant CLOTHES WASHER ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers' CITY — TEL. NO.
Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM No . Hollywood 705-5469
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. WATER HEATER LICENSE NO- 454677 CLASS C_36 CONTRACTORS DECLARATION DISTRICT NO. PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter 9 GAS SYSTEM OUTLETS
(commencing with Section 7000) of Division 3 of the Business OUTLETS OVER 'l 1
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL
454677 C-36 1 solar w/h DATE I . VALIDATION 0
` License Number Lic. Class
FINAL C9Contractor G+G Sol ar Date Jul -6-84 BY _-n—y -e.h
❑ I am exempt under Sec.
Ell,
B.&P.C. for this reason Date: Plan check fee 00PLUMBING PERMIT ISSUING FEE$ J
Signature
TOTAL FEE (� o
Plan check applicant
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Name n
I hereby affirm that I am exempt from the Contractor's License Address r- 2 A
5 9.0
Law for the following reason (Section 7031.5, Business and
Professions Code): City Tel. No. :' o o o 'o
❑ I, as owner of the property, will do the work and the 2 - 305 O
structure is not intended or offered for sale (Section
7044, Business and Professions Code). o v o IJ n -- U
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for L+ ? 10 9—8 Ll.
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.
nn �jcJ SEE REVERSE FOR EXPLANATORY LANGUAGE
�igna �oPer�mitt-e Date