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Home My Public Portal About6038 AGNES AVE_Sewer_7/14/1978_ 76A 642D CES08 A 7/76 APPLICATION FOR HERMIT SEWER—SEWAGE DISPOSAL COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION DISTRICT NO GROUP MAP PROC SSED BY FOR APPLICANT TO FILL IN BX P BUILDING � 3�. / / , ADDRESS / ,& LOCALITY �� CONNECTION DATA NEAREST r STATION DEPTH CROSS ST UPPER MANHOLE REFERENCE /7 � LOWER OWNER TYPE OF CONNECTION LENGTH FROM MAIL Y CURB P L ML TOPIL ADDRESS P C NO CO IMP NO JOB NO CITY L NO L GAL l - TRUNK PERMIT NO ROAD PERMIT NO DESCRIPTION LOT NO L/ AFFIDAVIT I WAIVER I [A5[N[NT RECORD INSTR NO DATE BLOCK TRACT ,� NO OF SLOGS SIZE OF LOT V (1 NOW ON LOT HWY OR ST WIDENING USE OF STATE ENCROACHMENT BUILDINGS PERMIT NO -# ,6 INDUSTRIAL �. CONTRACTOR / WASTE APPROVAL d ADDRESS I7 a C. CHARGEE ,r O 1 CONNECTION CHARGE FEE STATE TEL NO LIC �j� REIMBURSEMENT FEE LICENSE NO 7 CLASS L" NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR S SIGNATURE W HOUSE SEWER CONNECTING TO d PUBLIC SEWER 0 NEW HOUSE SEWER r N SEPTIC TANK SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD CONNECT ADDITIONAL ^ / HOUSE SEWER CONNECTING TO WORKf G• PRIVATE DISPOSAL SYSTEM SEPTIC TANK SEEP PIT(S) CONNECT ADDITIONAL,$ R. AND/OR DRAINFIELD WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL ❑ DRYWELL ❑ EXT N CESSPOOL DRYWELL MANHOLE ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER I BACKFILL SEPTIC TANKS ❑ SEEP PIT(S) ❑ CESSPOOLS ❑ OWNERS Issuance Fee s — AUTHORIZATION TOTAL FEE I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION "'�� AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON PLUMBING AND SEWERS TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT 1 AM PROPERLY REGI ST D AND/OR TO THE PUBLIC SEWER LICENSED AS REOUI D BY LOS ANGLE COUNTY A D ATE OF SIGNED THIS DAY OF 19_ CALIFORNIA OR THA 1 A THE LEGA NER OF A D IN NO TO OWNER OR RESIDE IN THE AS SCRIBED �SSEE�--IDE Nr TIAL PERTY SIGNATURE OWNERS AGENT OF PERMTTTE VALIDATIO WOr,KE S COM IE S j T FIjc,CK Mo CASH -JUI 14 1 U U 1 4 0 U m� POLICY HOLDER'(2c I � POLICY NUMBER S&E 663 D APPLICATION FOR PERMIT 1 S&E 68DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Department of County Engineer County of Los Angeles BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS ® CASSATT O GRIFFIN SUP T OF BUILDING LOCALITY FOR APPLICANT TO FILL IN CROSS S r LEGAL y OWNER DESCRIPTION LOT NO 3 MAIL BLOCK TRACT ADRESSr SIZE OF LOT�O ,NO OONBLOTS CITY TEL NO USE F 0LDDINGS DISTRICT NO I GROUP MAP BUI BK PG CONTRACTOR YG CONNECTION DATA ADDRESS l CITY TEL NO STATION �f'C�-�(��`j DEPTH [Q � MANHOLE REFERENCE r d fsBA�lR STATE / �yrCOUN / �✓ LOWER REGISTRATION NO aL- LJ COUNTY NO DESCRIPTION OF WORK FEE TYPE OF NN TION LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L PUBLIC SEWER @ $3 SO ..7 SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD Q $3 00 OVERFLOW SEEPAGE PIT DRAINFIELD PC _CO IMP NO /�O� JOB N00 EXTN CESSPOOL DRYWELL MANHOLE Q $2 00 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO ,j r CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT WORK TO HOUSE SEWER Q $1 00 PERMIT NO ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER S PERMIT $ 1 00 AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER _ NEW HOUSE SEWER SIGNED THIS QDAY OF / i ~ CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGENT /' SEPTICTANK SEEP PIT(S) ' ADDRESS v AND/OR DRAINFIELD 1 HEREBY CKNZ HAT I H READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ r AND STATE THAT IS CO ECT AND AGREE TO COMPLY WITH ALL COUNTCES ND STATE LAWS REGULATING ALTER REPAIR SEWER OR PLUMBING AND SSEWAGE DISPOSAL SYSTEM I HEREBY CERTM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND } \ LICENSED AS REQS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER / CALIFORNIA OR THE LEGAL OWNER OF T E ABOVE DESCRIBED RE31DEERTY BACKFILL SEPTIC TANKS❑ SIGNATURE SEEP PIT(S) ❑ CESSPOOLS❑ OF PERMITT 00'r yI._f-9 / ,1./,/ IOHN A LAM E COUNTY ENGINEER ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR CK b O ASH ` 2 7 2 � FEB 10 4 450 � 78A642D APPLICATION PR ERMIT CE808 8 89 lr COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING OF'IN A LAME CountyIn eer ADDRESS A4 40-3R, C TT D GRIFFIN Supof Buildmg LOCALITY NEAREST FOR APPLICANT TO FILL IN ceoss sT R4 11 LEGAL DESCRIPTION LOT NO OWNER BLOCK TRACT MAIL ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP r P OCESSED Y D BK PG CONTRACTOR ADDRESS CONNECTION DATA CITY TEL NO 0 STATION 0 DEPTH TATE MANHOLE REFERENCE r REGISTRATION NO ��Z COUNTY NO DESCRIPTION OFWORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3 00 TYPE OFetMMCTION LENGTH FROM C / SEPTIC TANK SEEPAGE PIT OR Y CUR P L M L TO P L J PITS AND/OR DRAINFIELD @ $3 00 OVERFLOW SEEPAGE PIT DRAINFIELD EXTN CESSPOOL DRYWELL @ $2 00 HOUSE SEWER CONNECTING TO P C NO PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO CONNECT ADDITIONAL BLDG OR WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNER SPERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING + APPROVALS DATE INSPECTOR S SIGNATURE TO THE PUBLIC SEW€R`i SIGNED THIS 2% OF 19 [1 NE HOUSE SEWER p OWNER OR COpAECT ADDITIONAL OWNERS AGENT �rLDING OR WORK ADDRESS + AND/OR TANK DRAISEELDPIT(S) 1 HEREBY ACKNOWLEDGE THAT I AVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CrSSPOOL ❑ DRY-WELL El WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED B LOS ANGELES COUNTY AND ATE CALIFOR jA OR T�IA THE fE AL 0 ER OF AB A ON HOUSE SEWER / �� ,/l DESCRIUREt ' IDEP BAOKFPIT(LL SEPTIC❑ CESS OOS (7' l� /J N� SIGNATOR / OF PERMITTE VALIDATION ROBERT A WOOD CK. m 0 CASH SUPERVISING MECHANICAL ENGINEER LI ,'L0 2 3 1 6 5 16 v u 5 (,, 0 L ca-A WORKERS_Ar_'OMPENSATION DECLARATION FEI ereby affir+n that % have a certificate of consent to self re or a certificate of Workers Compensation Insurance or 76A642D rtified copy thereof (Sec 3800 Lab C , CE 8081REV 1/83) APPLICATION FOR PERMIT cy No CompanyCertified copy is hereby furnishedSEWER - 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 OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE ADDRESS �, " S STATION DEPTH (This section need not be completed If the work Involved by theMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less , LOCALITY LOWER I certifythat in the performance of the work for which this NEAREST TYPE OF CONNECTION M L LENGTH FROM P CROSS ST L/�ti c4 N�'T V CURB P l M l TOPIL permit Is Issued I shall not employ any person In any manner PC NO so as to become subject to the Workers Compens tion Laws OWNER 1 ( f,(L(Z T CO IMP NO TOB NO MAIL TRUNK PERMIT NO ROAD PERMIT NO O 3 G A/ Date Applicant ADDRESS � AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE NOTICFT'9 APPLICANT If after making this Certificate of CITY C TEL NO 77 La 9 Exemption you should become subject, to the Workers LEGAL Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked 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 Division 3 of the Busi BUILDINGS CHARGES ness and Professions Code and my license Is in full force and effect `�+ F CONTRACTOR C_C- N n CONNECTION CHARGE FEE License Number 3 1 /'l�Lic Class C-J ` ADDRESS s� -� �' 2 a N ae L REIMBURSEMENT FEE 0. Contractor Date .�/ DISTRICT NO GROUP MAP P OCESSED BY O CITY S TEL NO 1 V f STATE / ` I� BK PG ❑ j am exempt under Sac of the L A Co LICENSE NO 3 b 7 5 CLASS �- �' V L O R-3 0 Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL �� V HOUSE SEWER CONNECTING TO DATE VALIDATI � B & P Code for the following reason PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR / N PITS AND/OR DRAINFIELD FIN Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM 1 / Signature CONNECT WORK O HOUSE SEWER BLDG OR / OWNER BUILDER DECLARATION OVERFLOW SEEPAGE PIT DRAINFIELD I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE ;21 0 Q 5 A Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE #fessions Code) SEWER OR DISPOSAL SYSTEM ' 0 0 2 1 5 0 El as owner of the property or my employees with wages as I their sole compensation will do the work and the structure Is not intended or offered for sale (Section 7044 Business and Professions Code) OWNERS I Permit $ ❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE 1 1 U 1 25 v licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR 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 OWNER OR issued (Sec 3097 Civ C ) OWNERS AGENT ADDRESS 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 jaws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the qaboa mentioned p party for Inspection purposes // r Signature of Permi ee Date SEE REVERSE FOR EXPLANATORY LANGUAGE