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Home My Public Portal About6327 AGNES AVE_Sewer_4/14/1960_ D CE808 APPLICATION FOR PERMIT eeoe s ae COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION BUILDING JOHN A LAMBIE County Eagmeer ADDRESS 48 CASSATT D GRIFFIN Sup t of Buildmg LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO Q 17 OWNER AIL BLOCK TRACT ,y— q DRESS � NO 07 BLDGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP P ESSED - BK PG CONTRACTOR ADDRESS j CONNECTION DATA CITY TEL NO STATION DEPTH / Z4 3 STATE MAN OLE REFERENCE ' UPPER REGISTRATION0 COUNTY j LOWER NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $S 00 TYPE 0 NNECTION &NGTH FROM PEPTIC TANK SEEPAGE PDIT OR $8 OO Y C P L M L TO P L EP GE PIT DRAINFIELD LL MANHOLE @ $2 00 00 HOUSE SEWER CONNECTING TO r C NO PRIVATE DISPOSAL SYSTEM @ $1 00 CO'IMP NO J 0 CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PE NO WORK TO HOUSE SEWER @ $1 00 ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHME SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ 1 2 Do CONNECTION HARGE FEE AUMOMATION TOTAL FEE REIMBURSIIMENT FEE HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ON APPROVALS DATE INSPECTOR S SIGMA URE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 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 DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION /� / % f AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYrDISCONNECT L DRYWELL❑ &l7'i7/7 / � /Iiy7 �d.Gf WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGREPAIR SEWER OR PLUMBING AND SEWERS DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUG AND LICENSED AS REOUIRED BY,LOS ANGELES COUNTY AND STATE OFN HOUSE SEWER CALIFORNIA OR THAT I AM THE LE AL OWNER OF THE ABOVE DESCRIBED RESIDE L PR RTY FLSEPTIC TANKS CESSPOOLS PI SIGNATURE OF PERMITTE ®p AMATION ROBERTA WOOD y p, CASg 'SUPERVISING MECHANICAL lNr3INB.ER LAC09294 �PR141 G A 400 ^S WORKERS COMPENSATION DECLARATION CE 808 D 80) CE APPLICATION FOR PERMIT 808 0 I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL Insure or a certificate of Workers Compensation Incurance or I�Z' "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 ,BUILDING STATION DEPTH DCertified copy Is filed with the county building inspection ADDRESS 3, � C _ UPPER department LOCALITY C_ MANHOLE REFERENCE LOWER Date Applicant NEAREST / oA ^ TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST (, v ,Q j Y CURB P L M L TO P L COMPENSATION INSURANCEOP C NO WNER d CO IMP NO JOB NO } AIL d (This section need not be completed If the work involved ADDRESS ��/ YL. TRUNK PERMIT NO ROAD PERMIT NO O by the permit is for one hundred dollars ($100) or less) //�� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO GATE U CITY Y THy:. I certify that in the performance of the work for which this LEGAL r 0 / em to permit is issued, i shall not person in any manner DESCRIPTION LOT NO P employ any P HWY OR ST WIDENING so as to become subject to the Workers Compensation Laws y'� 1;A11 rA „ (� pp / '/ //� / r r, % BLOCK TRACT-,;,9g/ // I STATE ENCROACHMENT (JJ Date `"� —Applicant I/�/�'1/1 41/L�7�Y1 / — NO OF BLDGS PERMIT NO a SIZE OF LOT f /l NOW ON LOT C/) NOTICE TO APPLICANT If after making this Certificate of Z Exemption j USE OF p you should become subject to the Workers BUILDINGS CHARGES Compensation provisions of the Labor Code, you must forth with comply with such provisions or this permit shall be '� CONNECTION CHARGE FEE � deemed revoked CONTRACTOR L n iL„� �(/ LICENSED CONTRACTORS DECLARATION /1e�v' (� REIMBURSEMENT FEE ADDRESS IJ DISTRICT No GROUP MAP PROCESS D BY hereby affirm that I am licensed under provisions of Chapter 9 (commencmg with Section 7000) of Division 3 of the Busi CITY P — TEL No 7% t) BK 'PG ness and Professions Code, and my license is in full force and LICENSE No 2// Y STATE LIC �°� C''9 f/ /x effect NO DESCRIPTION OF WORK FEE u HOUSE SEWER CONNECTING TO FINAL VALIDATION License Number / LIc Class C--'/Z PUBLIC SEWER DATE /0 SEPTIC TANK SEEPAGE PIT OR ontractor �U to Date 7 ��j��(] ,fir/) PITS AND/OR DRAINFIELD ---/// FINAL �,^ C/I HOUSE SEWER CONNECTING TO ❑ NeIPRIVATE DISPOSAL SYSTEM BY v5�_ I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG OR licensed architect or a registered professional engineer I 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 ness and Professions Code) 2 2 7 2 8 A 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON OIRA CTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I as owner of the property will do the work and the TO THE PUBLIC SEWER # 0 0 0 0 110 structure is not Intended or offered for sale (Section SIGNED THIS DAY OF I9 1 7044 Business and Professions Code) OWNER OR 2 0 0 1 8 0 0 OWNERS AGENT CONSTRUCTION LENDING AGENCY AODRESs o o • 1 a 0 0 v I hereby affirm that there is a construction lending agency j for the performance of the work for which this permit is I 0 2 2—80 Issued(Sec 3097 Civ C) 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 laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upZthbove mentioned property for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date