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Home My Public Portal About6156 ROSEMEAD BLVD_Plumbing__ WORKERS'COMPENSATION DECLARATION 1• APPLICATION FOR PLUMBING PERMIT 71 hereby gff(rm that I have a certificdte of-consent to self 20-0026 DPW 6/87 insure, or a certificate of Workers'Compensation Insurance, 7BA667A or a certified co thereof Sec. 3800, Lab. C.) COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS TaIP3636�5U Fremont Policy No. ompany ❑� Certified copy is hereby furnished. BUILDING ® FOR APPLICANT TO FILL IN(PRINT OR TYPE) ADDRESS 6156 Rosemead Blvd. I tion department Certified copy is filed with the county building Ins�gg� UMBER NFIXTURE OR ITEM @ FEE . LOCALITY Progressive Plbg. WATER CLOSET O Tempe Cit Date Appligont OLOngdPIl 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 Da-Ari Development— the permit is for one hundred dollars($100)or loss.) (JC LAVATORY Ilah MAIL •-\ I certify that in the performance of the work for which this L! ADDRESS permit is issued,I shall not employ any person in any manner 3 SINK Z CITY Monterey Park TEL.NO. so as to become subject to the Workers'Compensation Laws. DISHWASHERCONTRACTOR Progressive Plumbing I ojpA Date Applicant 3 CLOTHES WASHER ,Sdw ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of 4257 Auction Ave. #F Exemption, you should become subject to the Workers' SWIMMING POOL RECEPTOR Compensation provisions of the Labor Code, you must forth- LAWN SPRINKLER SYSTEM CIN Baldwin Park TEL.No. g62-2428 with comply with such provisions or this permit shall be STATE LIC. deemed revoked. WATER HEATER L9 11LICENSE NO. 478794 CLASS C-36 LICENSED CONTRACTORS DECLARATION DISTRICT NO� PR ED BY I hereby affirm that I am licensed under provisions of Chapter 9 3 GAS SYSTEM S OUTLETS :5 (commencing with Section 7000)of Division 3 of the Business OUTLETS OVER and Professions Code,and my license is in full force and effect. 5 PER SYSTEM FINAL Lf f6 ALI ION License Number 478794 Lic.Class C-36 DATEFINAL Contractor Progressive Plb e � BY C7�j% '�"� IY, ❑ I am exempt under Sec. I �� B.AP.C. for this reason Plan check fee Date: PLUMBING PERMIT ISSUING FEE$ 00 Signature TOTAL FEE SINGLE FAMILY Plan check applicant 5 HOME OWNER-BUILDER DECLARATION Name ACCT°v I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Address "2307 750°511 Professions Code): City Tel. No. 1 ITEMS ❑ I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section ® TOTAL 35101.50 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY GHEf'� °c` I hereby affirm that there is a construction lending agency for CHANGE .011 the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). Lender's Name 13000-00644 7/ 6/90 Lender's Address 1700 1 AM 90.4 l 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 aut orize representatives of this County to enter upon the UoKo ntio ope y for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE — S .lure of Permittee Date