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Home My Public Portal About6152 ROSEMEAD BLVD_Plumbing__ WPRKERS'COMPENSATION DECLARATION APPLICATION FOR PLUMBING PERMIT I hi reby affirm that I have a'certificate of consent to,self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 76AS67A or a.certified-copy thereof(Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS Policy No. WP893636mpany Fremont Certifibd copy is hereby furnished. BUILDING ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 6152 Rosemead Blvd. C Certified copy is filed with the county building inspec- NUMBER FIXTURE OR ITEM @ FEE tion department. LOCALITY Progressive Plbg. WATER CLOSET Temple Cit Date Appli;ant � . 0 ®� NEAREST CERTIFICATE OF EXEMPTION FROM WORKERS' BATH TUB cRoss ST. Longden COMPENSATION INSURANCE OWNER (This section need not be completed If the work Involved by MAIL SHOWER Da—Ari Development the permit is For one hundred dollars($100)or less.) ! ) LAVATORY so p� ADDRESS 678 W. Garvey I certify that in the performance of the work for which this permit is Issued,I shall not employ any person in any manner ?; SINK .7 0 A CITY Monterey Park TEL.NO. so as to become subject to the Workers'Compensation Laws. 3r DISHWASHER .50R CONTRACTOR Progressive Plumbing Date Applicant CLOTHES WASHER ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of SWIMMING POOL RECEPTOR 4257 Auction Ave. F Exemption, you should become subject to the Workers' CITY Baldwin Park TEL.N0962-2428 Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATERLICENSE NO. 478794 C-36 LICENSED CONTRACTORS DECLARATION �O DIST ICT E S Y I hereby affirm that I am licensed under provisions of Chapter 9 j GAS SYSTEM j�'' OUTLETS (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL r� V (DATION License Number 478794 Lic.Class C-36 DATE +� G/ FINAL ContractorProgressive Plbg Dte g D BY a ❑ I am exempt under Sec. W B.BP.C. for this reasonC' Plan check fee � Date: PLUMBING PERMIT ISSUING FEE$ 3 00 ® Signature TOTAL FEE 5a SINGLE FAMILY Plan check applicant r HOME OWNER-BUILDER-DECLARATION Name °g I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address 33-17 350.50 Professions Code): City Tel. No.❑ ITEMS I, as owner of the property, will do the work and the j structure is not intended or offered for sale (Section ® T13TAL. :350 o 50 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY C�{E �( I°9_i Ihereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued J CHANGE .130 (Sec. 3097, Civ. C.). Lender's Name 7/ 6/91, Lender's Address 1699 1 AM 9:39 1 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 apftrize representatives of this County to enter upon the bo ntio roperfy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permittee Date