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HomeMy Public PortalAbout5947 AGNES AVE_Sewer__ J� vL�� �6wy CEBOB3 62 76A6420 APPLICATION FOR PERMIT , �J COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILD'NG� JOHN A LAMBIE County Engineer ADDRESS WILLIAM A JENSEN Sup t of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO OWNE MAIL BLOCK TRACT ADDRESS NO OF SLOGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF DISTRICT NO GROUP BK MAP PROCESSED BY BUILDINGS P G /) / CONTRACTO �T /`- / / ' lJ ADDRESS z CONNECTION ATA / ZZZ CI ' TEL NO 3/� STATION DEPTH STATE MANHOLE REFERENCE REGISTRATION NO '� ❑ COUNTY 5, _ J NO DESCRIPTION OF,WORK FEE TYPE OF CONNECT' N LENGTH FROM >. HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L Q. PUBLIC SEWER @ $5 00 0 SEPTIC TANK SEEPAGE PIT OR P C NO PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO U HOUSE SEWER CONNECTING TO TRU PER / ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM @ $3 00 CONNECT ADDITIONAL BLDG OR ©D AFFIDAVIT WAIVER I EASEMENT RECORD INSTR NO DATE WORK TO HOUSE SEWER @ S300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 HWY OR ST WIDENING ALTER REPAIR OR ABANDON HOUSE _ SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ i 00 CHARGES AUTHORIZATION I TOTAL FEE S 00 CONNECTION CHARGE FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE SIGNED THIS DAY OF 19 OWNER OR NEW HOUSE SEWER OWNERS AGENT_ CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK SEEP PIT(SY 1HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY / WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOV DESIBRIBED RESIDENTIIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE (�/.� /[f// ,�(F.i�+/ BACKFILL SEPTIC TANKS ❑ � SEEP PIT(S) ❑ CESSPOOLS ❑ VALIDATION/—' ROBERT A WOOD CK M O CASH (/�/J SUPERVISING MECHANICAL ENGINEER LAUE) 9 1 6 2? CES08 3 62 76A642D APPLICATION FOR PERMIT r COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE County Engineer ADDRESS: WILLIAM A JENSEN Sup t of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CRD55 5T LEGAL DESCRIPTION LOT NO OW NE MAIL BLOCK TRACT �� / ADDRESS NO OF BLD GS SIZE OF LOT ^ NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY BK PG CONTRACTOR ADDRESS �,� CONNECTION DATA CITY TEL N STATION , \ DEPTH REGISTRATION NO �/Y �^-' ❑ COUNTY MANHOLE REFERENCE / { ( ` / UPPER NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION ~.J LENGTH FRO '+"' / HOUSE SEWER CONNECTING TO ` e:) Y CURB'� P L M L TO P L _� O PUBLIC SEWER @ $5 00 �,/ Q✓ SEPTIC TANK SEEPAGE PIT OR // P C NO PITS SAND DRAINFIELD @ $1000 CO IMP NO 1 /� 1. , JOB NO V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERM Q PRIVATE DISPOSAL SYSTEM @ $300 0 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DAT WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE @ $500 HWY OR ST WIDENING L ALTER REPAIR OR ABANDON HOUSE _ SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNERS PERMIT CHARGES s z o0 AUTHORIZATION TOTAL FEE / CONNECTION CHARGE FEE 1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Con REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESC ED EXI5TING DWELLING TO THE PUBLIC SEW APPROVALS DATE INSPECTOR S SIGN TURE SIGNED THIS D G�t�-� )g .� OWNER OR NEW HOUSE SEWER 1 OWNERS AGENT ^� wCONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK SEEP PIT(S) / I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD/ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM f CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOV DESLRYBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE /+ OF PERMITTEE ` BACKFILL SEPTIC TANKS ❑ SEEP PITS) El CESSPOOLS VALIDATION,--� ROBERT A WOOD CK M O CASH SUPERVISING MECHANICAL ENGINEER Ll,uo 9 0 6 1:n JM 2 1 0 D '7 00- /6 i7 I ` )(VORRERS COMPENSATION DECLARATION I Pere6y offirl'n that I have a certificate of consent to self r� insure, or a certificate of Workers Compensation Insurance or 76A642D a certified copy thereof (Sec 3800 Lab C , CE 808(REV 1/83) APPLICATION FOR PERMIT Policy No Company El Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OFIEXEMPTION FROM WORKERS BUILDING A� STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by the -�-��M �� � MANHOLE REFERENCE LOWER permit Is for one hundred dollars ($100)or less ) LOCALITY Lowea NEAREST a TYPE OF CONNECTION LENGTH FROM I certify that In the performance of the work for which this CROSS ST • Y CURB P L ML TOPIL permit Is Issued I'sholl not employ any person n any manner p A so as to beAccome subject to the rkers Co sation Laws OWNER ` 0. �.� /�I�� CO IMP NO JOB NPC O Lb_� MAIL TRUNK PERMIT NO ROAD PERMIT NO 17 (/ ADDRESS Date Applicant �� �� `• y AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT If r making this C Ificate of CITY �-. `i TEL NO LJ-•71 ©/ Exemption you should b o e subject to the Workers LEGAL Compensation provisions of t e Labor code you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed re""yoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under'provisions of Chapter USE OF 9 (commencing with Section 7000) of Div kion 3 of the Busl BUILDINGS CHARGES ness and ProfPssionS Code and my license Is 1n full force and t effect CONTRACTOR ! CONNECTION CHARGE FEE License Number Ltc ClassADDRESS REIMBURSEMENT FEE1106 DISTContractor Date CITY TEL NO BK N� GROUP BK MAP PROLE D BY ❑ I am exempt under Sec of the L A Co LICENSE NO �T ; CLASS U A-3 Q Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL ri HOUSE SEWER CONNECTING TO DATE VALIDATI W B & P Code for the following reason PUBLIC SEWER - 06 SEPTIC TANK SEEPAGE PIT OR N PITS ANO/OR DRAINFIELD FINAL Z /� Z Date HOUSE SEWER CONNECTING TO BY �7 3 2 0 I A " PRIVATE DISPOSAL SYSTEM # o e o 0 10 Signature r ' CONNECT ADDITIONAL BLDG OR Bl OWNER BUILDER DECLARATION WORK TO HOUSE SEWER e) C 1 hereby affirm that I am exempt from the Contractors License EOXTNFLOW CESSEPOOL DRYWELL GE PIT MANHOLE 'IELD 21 5 O Law for the following reason (Sectors 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE21 5 0 fessions Code) SEWER OR DISPOSAL SYSTEM 'U Vs owner of the property or my employees with wages as U 4 20-85 a their sole compensation will do the work and the structure Is not Intended or offered for sale (Section 7044 Business and Professions Code) OWNER S Permit 5 0 ❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE ,rd licensed Contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY _ , I hereby affirm that there Is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is I OWNER OR W Issued (Sec 3097 Civ C ) OWNERS AGENT -s xa..- .ADDRESS Lender s Name -_ _ Lender s Address - A I certify that I have read this application and state that the I U above Information Is correct I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers I and hereby authorize representatives of this County to enter 4 upo the above men t ned property for nspection p rpose I a `A � It Signature f P riA tree Date SEE REVERSE FOR EXPLANATORY LANGUAGE f �