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Home My Public Portal About4929 BALDWIN AVE_Sewer__ (2) 7BA6420 —_ li APPLICATION FOR PERMIT CE808 11-57 7 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1 DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING 4929 Baldwin ' -� ., JOHN A. LAMBIE, County. E meez ADDRESS CASSATT D. GRIFFIN. Sup t of i doin4 Temple 1 LOCALITY •� NEAREST FRESS OR APPLICANT TO FILL IN CROSS ST. 2 e er ons ruc 2 on o. ;, Residence LOT 0. 21 OWNER TRACT 848 MAIL an Gabriel V • ADDRESS NO.OF BLDGS. c 'l., NOW ON LOT CITY San GabrielTEL.NO. DISTRICT N0. GROUP MAP 7� ? Co. PG TOR L•D• i• • IS- ADD _ _ OX , -L p n/' CONNECTION DATA S ldwln Par} TEL.N0. Ed• 83024 STATION � %,v' DEPTH 3 STATE MANHOLE REFERENCE COUNTY REGISTRATION NO. LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO 3 00 PUBLIC SEWER @ $3.50 SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L. OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 HOUSE SEWER CONNECTING TO P.C. NO. PRIVATE DISPOSAL SYSTEM @ $1.00 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 SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERSPERMIT $ 21 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE 5 00 REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELL G APPROVALS DATE INSP CTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF-1 9NEW HOUSE SEWER OWNER OR New CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PIT(S) AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I 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 PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDENTIAL PROP TY. BACKFILL SEPTIC TANKS ❑ SIGNATURE �/ SEEP. PIT(S) 13 CESSPOOLS ❑ 1• OF PERMITTEE ®" VALIDATION ROBERT A. WOOD CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER r o 3 3 6 8 i'',Ei 12 1 p 5.0 0 WORKERS' COMPENSATION DECLARATION 11 hereby affirm that I have a certificate of consent to self in ure, or a certificate of Workers' Compensation Insurance, or 76A642D .1ertified copy thereof (Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy No. Company ❑ 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. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS °) 2`� S L p Al t r.f AVEtSIAON DEPTH I (This section need not be completed if the work involved by the LocAuiv LE T HOLE REFERENCE ,. z6L � owE permit is for one hundred dollars ($lOO) Or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Len ,j E v � mu S Oi. CURB P L M.L TO P.L.permit is issued, I shall not employ any person in any manner P.0 NO. so as to become subject to the Workers'Compensation Laws. owNER t,/�t✓� V L �- L ,42MP No. JOB NO MAIL ^ � 7L` �� J ` /� K PERMIT NO. ROAD PERMIT NO. DateApplicant ADDRESS `C G� 7 A, FIDAVIT WAIVER EASEMENT RECORD.INSTR NO. DATENOTICE TO APPLICANT: If, after making this Certificate of ❑Tv _ . TEL.NO. � 8 37�-15 Exemption, you should become subject to the Workers' LEGAL - 1 Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO N " Y2 - 2 HWY OR ST WIDENING comply with such provisions or this permit shall be deemed yif 48 revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.of SLOGS. ' PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOTuSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS R E 5 I C>E W 5C CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number LIC.Class ADDRESS REIMBURSEMENT FEE DISTRICT NO. GROUP MAP PROCESSED BY Z Contractor Date CITY TEL.NO BK PG �' ❑ I am exempt under Sec. _of the L.A. Co. LICENSE No.TATE CL SS ` G`ur Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL yyy tW HOUSE SEWER CONNECTING TO DATE I— G�/ VALIDATION Z / ^//�,•/�`,,o� B. 8 P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIElO 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 Contractor's License OVERFLOW N.,CESSPOOL, S OOL,DRYW LL,MANHOLE IELD LowLaw for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 7 fessions Code): SEWER OR DISPOSAL SYSTEM 'v ' I,as owner of the property,or my employees with wages as `T their sole compensation, will do the work and the structure �I_}_ is not intended or offered for sale (Section 7044, Business '- and Professions Code), OWNERS Permit $ �1 &`G- ❑ I, project (Section 044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the S7 � . 00 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. --- - -- CONSTRUCTION LENDING AGENCY 1101.•!. .: e).)_' SIGNED THIS DAY OF 19_ , i I hereby affirm that there is a construction lending agency '�atr�st,7r . J1_I 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 4j? "7 a•.ii 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 upon the above-mentioned property for inspection purposes. /99/ Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE