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Home My Public Portal About6313 AGNES AVE_Sewer_11/14/1956_ 76AS 213 8 d E 6633 69 APPLICATION DMSION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL. Department of County Engineer County of Los Angeles BUILDING -. WM J FOX COUNTY ENGINEER ADDRESS CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST CROSS ST LEGAL y DESCRIPTION LOT NO t/ OWNER MAIL BLOCK TRACT f ADDRESS NO OF BLDGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP BK PG CONTRACTOR S ADDRESS / ✓� CONNECTION DATA CITY TEL NO 7-- z STATION DEPTH STATE MANHOLE REFERENCE UPPER 3 D ,`� LOWER REGISTRATION NO / 7/ ❑ COUIJTY NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF CONNECTION L GTH 'ROM PUBLIC SEWER Q $ 3 50 Y CURB P L L TOP L HOUSE SEWER CONNECT NG TO PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG OR P C O WORK TO HOUSE SEWER 1 00 CO IMP NO JOB N ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PER IT NO DISCONNECT A(JD ABANDON SEWER STATE ENCROACHME AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO SEPTIC TANY SEEPAGE PIT OR PITS AND/OR DRAINFIELD 31 00 INDUSTRIAL CESSPOOL WASTE APPROVAL 2 00 CHARGES OWNER S PERMITS t 00 CONNECTION CHARGE FEE AUTHORMATION TOTAL FEE {REiMBURSEMENTFEE A�� /./ Z_ Zf I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON ` TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR SSIGNATURE /yp TO THE PUBLIC SEWER �(Jf ' SIGNED THIS _DAY OF 19. NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK SEEP PIT(S) ADDRESS AND/OR DRA114FIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL DRYNELL❑ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM 1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE'ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDEN L PROP TY BACKFILL SEPTIC TANKS❑ SEEP PIT(S) ❑ CESSPOOLS❑ SIGNATURE OF PERMITTEE WILLIAM J FOX COUNTY ENGINEER J VALIDATION R A WOOD CHIEF PLBG INSPECTOR 2 3 4 4 An Mv14 4 300 1n 7 WORKERS COMPENSATION DECLARATION CE 808 (D2 80) APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL Insure or a certificate of Workers Compensation Insurance or "fl a certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES , BUILDING AND SAFETY Policy No Company ( ` Certified copy Is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA BUILDINGSTATION DEPTH Certified copy is filed with the county building inspection ADDRESS UPPER department LOCALITY MANHOLE REFERENCE LOWER Date Applicant NEARESTTYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKLRS CROSS Sr Y CURB P L M L TO P L COMPENSATION INSURANCE P C NO OWNERMAIL S CO IMP NO JOB NO } (This section need not be completed if the[work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO Q by the permit is for one hundred dollars (SIOO) or less) AFFIDAVIT WAVER EASEMENT RECORD INSTR NO GATE O CITY I� TEL N I certify that in the performance of the work for which thisLEGAL permit is issued I shall not employ any person in any manner DESCRIPTION LOT NO HWY OR ST WIDENING so as to become subject to the Workers Compensation Laws U BLOCK TRACT STATE ENCROACHMENT w Date Applicant / NO OF BLDGS PERMIT NO a SIZE OF LOT JC / NOW ON LOT N NOTICE TO APPLICANT If after making this Certificate of Z Lxemption you should become subject to the Workers USE OF CHARGES Compensation provisions of the Labor Code you must forth BUILDINGS with comply with such CONNECTION CHARGE FEE p y provisions or this permit shall be CONTRACTOR deemed revoked 4 REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am liLensed under provisions of Chapter DISTRICT NO GROUP MAP PR s D BY 9 (commencing with Section 7000) of Division 3 of the Busi CITY NO �l ��f Q K PG ness and Professions Code and my license is in full force and LICENSE NO CSTATEILASS �>i4fil , effect NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL I� �j IDATION License Number Lic Class PUBLIc SEWER DATE SEPTIC TANK SEEPAGE PIT OR Contractor Date PITS ANDIOR ORAINF I ELO FINAL HOUSE SEWER CONNECTING TO ❑ PRIVATE DISPOSAL SYSTEM BY _^ / I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE PIT DRAINFIELD iness and Professions Code) EXTN CESSPOOL DRYWELL MANHOLE ALTER REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic or Reg No Date HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors OWNERS Permit f License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE ess and Professions Code) I HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CON YRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I as owner of the property will do the work and the TO THE PUBLIC SEWER structure is not intended or offered for sale (Section SIGNED THIS DAY OF to �9_ 4'6 3 5 A 7044 Business and Professions Code) OWNER OR OWNERS AGENT CONSTRUCTION LI NDING AGENCY o 0 0{0 1 0 I herebv affirm that there is a construction lending agency ADDRESS -� 2 0 o 1 x 0 0 for the performance of the work for which this permit is Issued(Sec 3097 Civ C) a 0 0 0 1 8 0 0 5 Lender s Name Lender s Address 0403-81 I certify that I have read this application and state that the above information is correct I agree to comply with all Courty o ances and State laws regulating Plumbing and Sewers nd reby autho a representatives of this County to enter on he above men roperty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature f Permittee Date