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Home My Public Portal About6323 AGNES AVE_Sewer__ CE808a APPLICATION FOR PERMIT-COUNTY OF LOS ANGELES ]. SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEES BUMDING AND SAFETY DMSION BUILDING JOHN A LAMBIE Couatp T}ngineer ADDRESS CASSATT D GRIFFIN Sup t of Builtbag LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST 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 PROCESSED BY BK PG CONTRACTOR ADDRESS I CONNECTION DATA CITYk:LA, TEL NO 6 STATION DEPTH TATE REGISTRATIO NO Q COUNTY MANHOLE REFERENCE UPPER NO DESCRIPTION OF WOR FEE LOWER HOUSE SEWER CONNECTING TO PUBLIC SEWER Q $8 00 TYPE OF CONQCTION LENGTH FROM SEPTIC TANK SEEPAGE p T OR $S 00 Y CU P L M L TO P L OW S PI KATRFTELD ` @ $2 00 HOUSE SEWER CONNECTING TO P 0 PRIVATE DISPOSAL SYSTEM Q $1 00 CO IMP NO tOt NO CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO WORK TO HOUSE SEWER $1 00 ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHM SEWER OR DISPOSAL SYSTEM $1 00 PERMIT NO INDUSTRIA _WASTE A OVAL CHARG OWNER'S MINT 5 2 ROC CONNECTION CHARGE FEE V AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON APPROVALS DATE INSPECTOR S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER SIGNED THIS DAY OF 1J_ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK SEEP PIT(S) ADDRESS AND/OR DRAINFIELD Q , 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR 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 G L OWNER OF THE ABOVE DESCRIBED RESIDE L PROPTY BACKFILL SEPTIC TANKS❑ SIGNATURE SEEP PITS ❑ CESSPOOLS❑ OFPERMITTEE � ®► ATION ROBERT A WOOD M p, cgH r GUPERVISING MECHANICAL ENGINEER ` 2 7 5 4U -SET' 1 '7 s 0 A 4 00 `° WORK ,�RS COMPENSATION DECLARATION / I hereby affirm that I have a certificate of consent to self Insure or a certificate of Workers Compensation Insurance or 76A642D LS 6certifiea c y they of (Sec 3800 Lab C ) CEBOB(REV B/BI) APPLICATION FOR PERMIT Policy No s� Company SkPl'� �� ®s _ Certified copy is hereby furnished T SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY' dep rtme Date a� Applicant GAS ,cam SAS ___ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDINGSTATION 1 22 DEPTH COMPENSATION INSURANCE ADDRESS 7 J Y (This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE S U UPPE R permit is for one hundred dollars ($100)or less ) LENGTH FROM NEAREST � ' TYPE OF CONNECTION I certify that In the performance of the work for which this CROSS ST V Y CURB' P L ML TO P L permit is Issued I shall not employ any person in any manner PC NO so as to become subject to the Workers Compensation Laws OWNER CO IMP NO JOB NO ' MAIL i Date Applicant ADDRESS TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If after making this.Certificate of CITY TEL NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE 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 ENOOACHMENT �q ' LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT U/71 SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE of (p t 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 - g effect - L CONTRACTOR Al` CONNECTION CHARGE FEE License Numberahl 6�\ LIC Class C�� ADDRESS CL REIMBURSEMENT FEE O pp DISTRICT NO GROUP MAP PROCESSED BY r V Contraclorc -Date 1��'" 1 CITY , TEL NO STATE❑ I am exempt under Sec of the L A Co LICENSE NO - CLAssIl NO DESCRIPTION OF WORK FEE O V Plumbing Code and/or Sec of the FINAL i W HOUSE SEWER CONNECTING TO , DAT VALIDAT N N B & P Code for the following'reason PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR FIN Z Date PITS AND/OR DRAINFIELD PRIVATE D SEPOSAOLNSY TEMG TOHOUSE - 275 6 0 A Signature CONNECT ADDITIONAL BLDG OR OWNER BUILDER DECLARATION` WORK TO HOUSE SEWER , ® 7 # o se o e 1 ,10 OVERFLOW,SEEPAGE PIT DRAINFIELD 1'hereby affirm that I am exempt from the Contractor s License EXTN CESSPOOL DRYWELL MANHOLE Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE P ,, ' ' o - 2 7 5 0 fessions Code) SEWER OR DISPOSAL SYSTEM F ❑ =� I as owner of the property or my employees with wages as r *e,e o_2 7 5 0 0 their sole compensation will do the work and the structure a - a Is not intended or offered for sale (Section 7044 BusinessPermit g r 0 7 2 9 a 8 7 and Professions Code) I OWNER'S ' ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE r; 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 F 19�� for the performance of the work for which this permit 1s OWNER OWNERSAGENT T , t Issued (Sec 3097 Civ C ) ADDRESS Lender s Name Lender s Address > I certify that I have read this application and state that the r 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 theabove- ent o ed property for Inspection purposes f 1 - A. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE