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Home My Public Portal About4948 BALDWIN AVE_Sewer__ 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