HomeMy Public PortalAbout6148 ROSEMEAD BLVD_Plumbing__ _ WORKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT
F hereby affirm that I have a certificate of-consent to self 20-0026 DPW 6/87 L�
insure, or a certificate of Workers'Compensation Insurance, 76A667A ILII
or a certified copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS
Paley Na.WP8936365�0ampany Fremont
❑ ' CertiNed copy is hereby furnished.
® FOR APPLICANT TO FILL IN(PRINT OR TYPE) BUILDING
Certified copy is filed with the county building inspec- ADDRESS 6148 Rosemead Blvd. 1C
ti n department. NUMBER FIXTURE OR ITEM ® FEE LOCALITY
Progressive Plbg. WATER CLOSET Tem le Cit
Date Appli4an � 671,50
,591 cliosss T. Longden
CERTIFICATE OF EXEMPTION FROM WORKERS' LIP BATH TUB 115C 45 o
COMPENSATION INSURANCE SHOWER OWNER Da-Ari Development
(This section need not be completed if tho work involved by MAIL
the permit is for ono hundred dollars($100)or loss.) LAVATORY )JA 50 ADDRESS 678 W. Garvey
I certify that in the performance of the work for which this
permit is issued,I shall not employ any person in any manner SINK MontereyPark TEL.NO.
� 5� o12 1 CITY
so as to become subject to the Workers'Compensation Laws. DISHWASHER
, CONTRACTOR progressive Plumbing
Date Applicant aj CLOTHES WASHER 5 ADDRESS 4257 Auction Ave. #F
NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- CITE' Baldwin Park TEL. No. 962-2428
LAWN SPRINKLER SYSTEM
with comply with such provisions or this permit shall be STATE LIC.
deemed revoked. `� WATER HEATER 5 LICENSE NO. 478794 rsi.Ass C-36
LICENSED CONTRACTORS DECLARATION IS RICT NO. - BY
I hereby affirm that I am licensed under provisions of Chapter 9 �j GAS SYSTEM OUTLETS ;�,��� .1 j 0 �JY
(commencing with Section 7000)of Division 3 of the Business OUTLETS OVER
and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL ff'- 6 V LID ION n
License Number 487894 Lic. Class C-36 DATE �/ lC
Progressive Plbg. _ FINAL `jyr
Contractor Date o`
❑ I am exempt under Sec. C
W
BAP.C. for this reason G
Plan check fee CC
Date: PLUMBING PERMIT ISSUING FEE$
Signature
TOTAL FEE
Plan check applicant 5
SINGLE FAMILY :�
HOME OWNER-BUILDER DECLARATION Name ACTo4
r C 7�T-f)o�-t:r
,
Law for the following reason (Section 7031.5, Business and
i�lr
Professions Code): City Tel. No.
❑ I, as owner of the property, will do the work and the 1 IsENS
structure is not intended or offered for sale (Section ® TOTAL M-50 o 503
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHECK .50.50
I hereby affirm that there is a construction lending agency forCHANGE o��t
the performance of the work for which this permit is issued
(Sec. 3097, Civ. C.).
Lender's Name 031GO-CIIc.1 7/ 6/9113
Lender's Address
13698; 1 AN 9:3,-
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
71-0�e-mentioned property for inspection purposes.
a n SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of rmittee Date