HomeMy Public PortalAbout4948 BALDWIN AVE_Sewer__ (2) OE �S��J�'DF L07'
"TEMPLE CT�V
7w- PLICATION FOR PERMIT
OU O S ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENTO COUNTY ENGINEER
BUILDING SAFETY DIVISION BUILDING
ADDRESS
IOHN A �AND
MBIE County En sneer
CASSATT D GRIFFIN Supt o4 Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN ceoss sr
LEGAL 1�
SCRIPTION LOT NO I OWNER ✓c/ ✓G�
B OCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITYUSOF
TEL NO r
13UILDINGS GGG'�`rJ DISTR CT NO GROUP MAP PROCESfED
BK PG
CONTRACTORLS OZ /
ADDRESS CONNECTION DATA
CITY`r�,��y�'�/� TEL NOI�.Q'S-��fJ,�j STATION DEPTH A/
UPU
REGISTRATION NO COUNTY MANHOLE REFERENCE I G LOW R
No DESCRIPTION OF WORK FEE ,
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ 00 TYPEOF CTIO LENGTH,6 OM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L MLT P L /
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
/��cO�Sd:.Q
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT ,S
WORK TO HOUSE SEWER @ $1 00
ALTER
REPAIR OR
DISPOSAL ABANDON
HOUSE @ $1 OO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE J
AUTHORIZATION �y
TOTAL FEE / a0 REIMBURSEMENT FEE
CON
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTINGDATE A CONTRACT WITH THE HEREINAMED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER WIN -i 9
SIGNED THIS DAY N!/i%L/df'� 19�` NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGE�NITA G BUILDING OR WORK
ADDRESS %�t7 f G9` SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE AT 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 ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT All THE LEGAL�OHFtR OF THE ABOVE SEEP PIT(S) ❑ CESSPOOL ®
DESCRIBED RESIDENT ROPERTY
jJU,/) BACKFILL SEPTIC TANKS ❑ /�
SIGNATURE .,
OF PERMITTE
®FATIO ROBERT A WOOD
CK m 0 SUPERVISING MECHANICAL ENGINEER
LAU0 4 0 5 5 JAN 3 10 0 700-
y
44,
(
i
WORKERS'COMPENSATION DECLARATION CE 808 ((2-80) APPLICATION FOR PERMIT
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL Lel
insure, or a certificate of Workers'Compensation InsLrance,or
a certifi cony the!p�4t ems. 380�DA1#b`:C/),w��.��}��r�j� COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy IVB (•7✓ s Cowfpan3
FOR APPLICANT TO FILL IN CONNECTION DATA
Certified copy is hereby furnished.
BUILDINGADDRESS - a+' STATION DEPTH
..-.: �. ;�'.....;,;.
Q Certified copy is filed with the county building inspection UPPER
d/,eparrment.. LOCALITY MANHOLE REFERENCE LOWER
Date Applicant L2Il"'' - r" NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss sr. Y. cuRe P.L. M.L. TO P,L. i
COMPENSATION INSURANCE P.C. NO.
OWNER CO. IMP. NO. JOB NO.
MAIL
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. LU
by the permit is for one hundred dollars ($100) or less.) �
AFFIDAVIT WAIVER EASEMENT RECORD, INSTR, NO. PATE
CITY TEL. NO. t!-
1 certify that in the performance of the work for which this LEGAL
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. C
BLOCK TRACT STATE ENCROACHMENT Q
Date Applicant NO. OF BLDGS. PERMIT NO.
NOTICE TO APPLICANT: If, after making this Certificate of slzE of Lor Now ON LOT 0
Exemption, you should become subject to the Workers' USE OF ,,5BUILDINGS CHARGES
Compensation provisions of the Labor Code, you must forth- EJJ
with comply with such ,,.% CONNECTION CHARGE FEE
p y plOVISIOr15 Oi this permit shall be CONTRACTOR
deemed revoked.
€}( REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS:ty L -x:' d� "+•� .rte
DISTRICT NO- GROUP MAP PROCESSED BY
I hereby affirm that I am licensed under provisions of Chapter CITY , ,•'z `r%%> .rEL. No: ir� �^ BK PG
9 (commencing with Section 7000) of Division 3 of the Busi-
ness and Professions Code, and my license is in full force and STATE ,! LIC. "gig{
LICENSE NO.—.r�' 'F&.ry, CLASS
effect. } _ NO. DESCRIPTION OF WORK FEE
K. ;�!,o HOUSE SEWER CONNECTING TO FINAL VALIDATION
License Number Lic.Class \ PDBLIC SEWER DATE
}}} ,( 1 �.//.r...+,+�..yy TyF,eSEPTIC TANK,SEEPAGE PIT OR
Contractor*W .i ,I,� •tole' `AA PITS AND/OR DRAINFIELD
FINAL
1" HOUSE E DISPOSAL
CONNECTING TO BY
❑ •"'�' PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as lam a
licensed architect or a registered professional engineer CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER
acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD
/�
EXTN.,CESSPOOL, DRYWELL, MANHOLE
4; lne$$and Professions Code). 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 Contractor's OWNERS Permit f
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
1, 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 Is
7044, Business and Professions Code). OWNER OR
OWNERSAGENT
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
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
upon the.;above-ment)6q; d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
WORKERS COMPENSATION DECLARATION • r 0808(80) APPLICATION FOR PERM IT-
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
Insure or a certificate of Workers Compensation Insurance or
a certified copy t 380P„Ipb c�)/� _ _i COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy any
Certified copy Is hereby furnished FOR APPLICANT TO FILL IN ___.. CONNECTION DATA
BUILDING STATION DEPTH
Certified copy is filed with the county building Inspection ADDRESS UPPER
DaJd'�j part a `�' P�� A/( LOCALITY R MANHOLE REFERENCE LOWER
e L Applicant// 1yj&eoiCIL. yL�/// / NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST r CURB P L M L TO P L
COMPENSATION INSURANCE P C NO
OWNER CO IMP NO JOB NO
MAIL d
(This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO ROAD PERMIT NO O
by the permit is for one hundred dollars ($100) or less) AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO I DATE L)
CITY ,�' TEL NO
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
BLOCK TRACT STATE ENCROACHMENT U 0
Date Applicant No of BLD GS PERMIT NO �
NOTICE TO APPLICANT If after making this Certificate of SIZE OF LOT NOW ON LOT Z
Exemption you should become subject to the Workers USE OF
Compensation BUILDINGS CHARGES
p provisions of the Labor Code you must forth
with comply with such provisions or this permit shall beCONNECTION CHARGE FEE
deemed revoked CONTRACTOR
LICENSED CONTRACTORS DECLARATION 000,
REIMBURSEMENT FEE
I hereby affirm that I am licensed under provisions of Chapter DISTRICT No GROUP MAP PROCESS^D BY
9 (commencing with Section 7000) of Division 3 of the Busi CITY TEL NO p
b►'� So �”
ness and Professions Code and my license Is in full force and STATE LIC
effect LICENSE NO CLASS
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINALJ7 VALIDATION
License Numberw -t!!L/_J
LClass ` PUBLIC SEWER DATE /TL
SEPTIC TANK SEEPAGE PIT OR
ContractoruN i PITS AND/OR DRAINFIELD
FINAL
HOUSE SEWER CONNECTING TO BY
F1 PRIVATE DISPOSAL SYSTEM v
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
loess 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 s 4 4 9 8 R
License Law for the following reason (Section 7031 5 Busi AUTHORIZATI NJ TOTAL FEE
ness and Professions Code) # D D e o 1 0
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
OIRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
I as owner of the property will do the work and the TO THE PUBLIC SEWER 2 D D 1 4, 0 0
structure is not Intended or offered for sale (Section SIGNED THIS DAY OF 19_
7044 Business and Professions Code) OWNER OR D D o 1 4,000'
OWNERS AGENT
CONSTRUCTION LNNDING AGENCY ADDRESS 0323-81
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit Is
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 Courty
ordinances and State laws regulating Plumbing and Sewers
and hereb authorize representatives of this County to enter
upon e t d property for Inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Date