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Home My Public Portal About6322 AGNES AVE_Sewer__ E6D IS& ssnss APPLICATION! FOR PERMIT s DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles 6, 52 .2 - :27 d44nan BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS ® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY --, x 0 _- ,,,h "- FOR APPLICANT TO FILL IN CROSS sT A LEGALLO�i' ` Y OWNER DESCRIPTION NO - ` MAIL BLOCK TRACT/Y], 8, 6. - 132 r /� — 13 ADDRESS ��/ NO OF BLDGS CITY �—� TEL NO SIZE OF LOT NOW ON LOT USE OF BUILDINGS DISTRICT NO GROUP MAP r BK PG CONTRACTOR �.J` �� — ADDRESS CONNECTION DATA STATJON DEPTH CITY TEL NO MANHOL E RENCE PER TATE LOWER REGISTRATION NO Q ❑ COUNTY NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF CONNECTION OM PUBLIC SEWER @ $350 Y CURB PL M L OP SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD Q $3 00 OVERFLOW SEEPAGE PIT WRAI Q64 R P C NO Q $2 00 CO IMP NO JOB NO HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMI 0 ROAD PERMIT NO CONNECT ADDITIONAL BLDG OR STATE ENC ACHMENT WORK TO HOUSE SEWER Q $1 00 PERMIT 54 ALTER REPAIR OR ABANDON HOUSE INDUST IAL SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL ` CHARGES CONNECTION CHARGE FEE OWNER S PERMIT 8 1 00 REIMBURSEMENT FEE AUTHORIZATION TOTAL FEE 3 1HAVE 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 DAY OF 19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGENT SEPTICTANK SEEP PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL DRYWELL❑ ZSR AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER R PAIR SEWER OR PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENT PROPS Y BACKFILL SEPTIC TANKS❑ SIGNATUREH A", , Y_ f SEEP PITS) ❑ CESSPOOLS[] OF PERMITTEE JOHN A LAMBIE COUNTY Et4GINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR SH _ 110,2 A4 3 APR 4 A 300 N �p r WORKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self Insure or a certificate of Workers Compensation Insurance or 76A642D a certified copy thereof (Sec 3800 Lab C ) CE 808(REV 8/8t> Policy No Company @= APPLICATION FOR PERMIT ❑ 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 I Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA T CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION �, 5-� DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by the ) LOCALITY f MANHOLE REFERENCE permit is for one hundred dollars ($100)or less ) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this cRoss sT b Y CURB P L ML TO P L > permit Is issued 11 shall not employ a person in any anner t P C NO so as to become subject to the Wor r Comp sat, aws OWNE�. ` \L QC CO IMP No JOB NO J O U MAILa3 "JAS rcOAD PERMIT NO 19 ��— Date CW(18 3- Applicant , w ADDRESS _ v*-� I- .. _ AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE �-® '� NOTICE TO APPLICANT If after making this Certificate of I CITY { TEL N I— Exemption you should become subject to the Workers U LEGAL Compensation provisions of the Labor code you must forthwith DESCRIP710N lOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed H revoked BLOCK TRACT STATE ENCROACHMENT - Z LICENSED CONTRACTORS DECLARATION + NO OF BLDGS PERMIT N SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter 4111, USE of d 9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS CHARGES ness and Professions Code and my license Is In full force and - effect CONTRACTOR CONNECTION CHARGE FEE License Number LIC Class ADDRESSREIMBURSEMENT FEE Contractor Date CITY TEL NO DISTRICT NO GROUP MAP PG PROCESSED BY 5d BK EJ STATE LIC 3 1, ro I am exempt under Sec of the L A Co LICENSE NO css t Plumbing Code and/or Sec of the NO DE CRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE I1 s/ VALIDATION r B & P Code for the following reason PUBLIC SEWER �J SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD X FINAL + Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractors License OVERFLOW SEEPAGE PIT DRAINFIELDEXTN CESSPOOL DRYWELL MANHOLE Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE fess,ons Code) SEWER OR DISPOSAL SYSTEM 2 7 0 A El as owner of the property or my employees with wages as their sole compensation will do the work and the structure Is not Intended or offered for sale (Section 7044 Business #'o 0 0 0 1 0 and Professions Code) OWNER S Permit $ /v ISO 2 0 - 2750 2 `j 0 El as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE SU licensed contractors to construct the project (Section 7044 1 HAVE AT THIS'DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO O p O 7 5 O r Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY 0 5 19-83 I hereby affirm that there Is a construction lending agency SIGNED THIS DAY 1 for the performance of the work for which this permit is OWNER OR Issued (Sec 3097 Civ C ) OWNERS AGENT J ADDRESS ¢ Lender s Name + Lender s Address certify that I have read this application and state that the " above information Is correct I agree to comply with all County ordinance nd State laws regulating PlunlAing and Sewers - and her authorize pre tatives ounty to enter upon a ove me I ned per r sp Ion purposes LJgnature of er tee Date SEE REVERSE FOR EXPLANATORY LANGUAGE