HomeMy Public PortalAbout5649, 5651, 5653 BALDWIN AVE_Sewer__ (2) DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
d"vSDIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING A �J NEAREST
ADDRESS A!3d��L/J/.H �Jy� CROSS ST.
LOCALITY � � � DISTRICT NO. SERIAL NO. PERMIT NO.
CROSS ST. / A ���7� (0Z 9/ S
�� REC�EQIVED BY Ready for Inspection DATE ISSUED
OWNER N_ J:j
MAIL
ADDRESS USEZONE I OCCUPANCY BK MAP PG
CITY TELAO.
CONTRACTOR .e.7 , s em. & � CO.IMP.NO.
ADDRESSQ JOB.N0.
CITY�h,�AVle e'/ TEL.QNO1�7/' TRUNK PERMIT NO.
f G 6✓ Q
REGISTRATION N0COUNTY ROAD PERMIT NO. �p v
.
LEA
DESCRIPTION 0 / STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL - •-
NO.OF BLDGB-
SIZE OF LOT V NOW ON LOT CHARGES
USE OF /�
BUILDINGS /l } CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q ; 8.50 RECEIPT NO. I DATE BY
HOUSE SEWER CONNECTING TO _
PRIVATE DISPOSAL SYSTEM 1.00 —
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWERI _ CONNECTION DATA
AND/OR DISPOSAL SYSTEM 1.00
P TSEPS NDIC /OR� DSRAINFGELDTOR 2.00 I STATIONv' DEPTH
CESSPOOL—DRYWELL `� ��' /
SPECIAL CONDITIONS ONLY 2.00 I MANHOLE REFEI�E�
UPPER- (( CE��r O f LOWER
'--
TYPE OF DONNE
CTIAN LENGTH FROM I
Y. CURB L/ P.L.- - --- M.L.TO P.L 2 L)
OWNERS PERMIT $ I 1 00
AUTHORIZATION I TOTAL FEE I � ?v J
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS...._r�__...._...DAY OF___ . i � •••I9.L.0 NEW HOUSE SEWER / •����t,�r /�..?! J �
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT._. J �?� 'lx: BUILDING OR WORK
ADDRESS___ C� .s .s�,fi��w -_......---__---•-_•_• ANSEPD/OR DRAINFIELD IT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED�eR'ESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE / �C SEEP.PIT(S)E] CESSPOOLS
OF PERMITTEE _�-v.•�!eI_l� C t !t `.._.__.--•---•-_.
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