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HomeMy Public PortalAbout5307 BALDWIN AVE_Sewer__ U r j ti 9 76A649D CE9081REV 6/781 ©i APPLICATION FOR PERMIT ' SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT NO GROUP MAP PROLE BY 0 D ^1 `8lC /PG ADDRESS l/ ��tJ( GL.. Aw LOCALITY — G�/T CONNECTION DATA NEAREST STATION DEPTH I r CROSS ST t UPPER MANHOLE REFERENCE LOWER OWNER G� TYPE OF CONNECTION LENGTH FROM MAIL506 7 // � / y CURB PL M L TO P L ADDRESS J AC/ ) PC NO 1 1 A CO IMP NO JOB NO CITU / e�TEL NO r LEGAL TRUNK PERMIT NO ROAD PERMIT NO DESCRIPTION ' LOT NO r AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE BLOCK TRACT NO OF BLDGS SIZE OF LOT NOW ON LOT HWY OR ST WIDENING USE OF BUILDINGS STATE ENCROACHMENT PERMIT NO rs ,�.� INDUSTRIAL CONTRACTOR WASTE APPROVAL I ADDRESS //JJ//��.. CHARGES CITY /"vii ( TEL NO �� CONNECTION CHARGE FEE STATE LIC n REIMBURSEMENT FEE LICENSE NO �! CLASS 3 NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTORS SIGNATURE V HOUSE SEWER CONNECTING TO PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR NEW HOUSE SEWER PITS AND/OR DRAINFIELD CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO r BUILDING OR WORK PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL B I DG OR SEPTICTANK SEEP PIT(S) WORK TO HOUSE SEWER AND/OR DRAINFIELD 1 OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL Cl DRYWELL❑ EXTN OL DRYWELL MANHOLE / SEWER ER"4O P ISPOSABL SYSTEM OUSE �.j� ALTER REPAIR SEWER OR r �' l.7 SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER t BACKFILL SEPTIC TANKS❑ SEEP PITIS)❑ CESSPOOLS❑ OWNER'S Permit s � Z, AUTHORIZATION rTOTAL FEE / A=ION @5560A t I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON TRACTOR CONNECT THE ABOVE DESCRIBED EXISTING DWELLING L � // # O O�0 O 1 O TO THE PUBLIC SEWER / SIGNED THIS DAY OF 19_ OWNER OR 2oD1400 OWNERS AGENT ADDRESS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION v 1 YY r r AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS I HEREBY CERTIFY THA I M P EGISTERED AND/OR LICENSED AS REO IRED L S A GELES C LINTY AND STATE OF CALIFORNIAC TH I AM HE LEGA OWNER O AND INTEND TO RE SIDE IN THE ABOV ES I ED S ENTIAL P OPERTY SIGNATURE OF PERMITTEE �► WORKERS COMPENSATION DECLARATION l,here4 affirm that I have a certificate of consent to self 200051 DPW 6/89 Insure or a certificate of Workers Compensation Insurance or 76A6420 a c- Q ;o�go���P3800 L�� amu ,, APPLICATION FOR PERMIT FPo�licy No' J�1 Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the ounty building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de�poe�rtmce�n�t ���{�� Date�lLp cant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTI FROM WORKERS BUILDINGW+ F h COMPENSATION INSURANCE ADDRSTATION �/v f DEPTH ESS �/ (This section need not be completed If the work Involved by the MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less ) LOCALITY e e C 7`��O LOWER NEARESTTYPE OF CONNECTION LENGTH FROM I certify that In the performance of the work for which this CROSS ST W n Q Q�J'V Y CURB PL M L TO P L permit Is Issued I shall not employ any person In any manner LEGAL PC NO so as to become subject to the Workers Compensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant NOTICE TO APPLICANT If after makingthis Certificate of AssessoR AFFIDAVIT WA a EASEMENT RECORD INSTIL NO DATE MAP BOOK PAGE ACU PARCEL OHO Exemption you should become subject to the Workers NO OF BLDGS Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING 7 comply with such provisions or this permit shall be deemed USE OF revoked BUILDINGS STATE ENCROACHMENT /-7 PERMIT NO Y o�7 LICENSED CONTRACTORS DECLARATION OWNER Q,C Q�e,� (,I, C I hereby affirm that I am licensed under provisions of Chapter 13 9 (commencing with Section 7000) of Division 3 of the Busl MAIL ADDREss5?7Q Ci/d1(1�JZ CHARGES /�p� ness and Professions Code and my license Is In full force and (-t� nev effect (�/ CITY TEL{f /gam 7s CONNECTION CHARGE FEE License NuAm�b^e(r,399 /c7� YLic Class ��Q � REIMBURSEMENT FEE Con r C r I4" _- 9"L4 1%�/UOte /��f.�9 y CONTRACTOR e ' /Z � / DISTRICT NO GROUP MAP PROCESSED BY ADDRESS, Qio� /Ie �j7 p Ex PG ❑ I am exempt under Sec of the L A Co C } P CITY J�/J � TEL�NOi 0 gf8 3 j-OD G � G a 0 Plumbing Code and/Or Sec of the STATE /� ) LIC �r FINAL / V LICENSE NO Sq-115 jL CLASS C DATE l 1+�y /]{ VALIDATION Z 6 8 P Code for the following reason NO DESCRIPTION OF WORK FEE 1 l ` (J O HOUSE SEWER CONNECTING TO /yd FINAL w F� ate PUBLIC SEWER BY SEPTIC TANK SEEPAGE PIT OR a. Signature f PITS AND OR DRAINFIELD V) OWER BUILDER DECLARATION HOUSE SEWER CONNECTING TO ® Z PRIVATE DISPOSAL SYSTEM _ I hereby affirm that I am_exempt from the-Contractor s License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031 5 Bulsness and Pro WORK TO HOUSE SEWER 10 ERFLOW SEEPAGE DRAINFIELD tTt.lT�A feSSIOnS Code) N CESSPOOL E PIT IT DL MANN ❑ 1 as owner of the property or my employees with wages as ALTER REPAIR O ABANDON HOUSE SEWER OR DISPOSAL SYSTEM � their sole compensation will do the work and the structure 3, 03 73.50 Is not Intended or offered for sale (Section 7044 Business and Professions Code) h'1 ITEMS ❑ I as Owner of the property am exclusively contracting with OWNERS Permit $ TIJTAL �' m licensed contractors to construct the project (Section 7044 50 Business and Professions Code) AUTHORIZATION TOTAL FEE CHECK 73.90 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C CT jO /LSA r I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DNELLING TO THE PUEL R !! ® CHANGE 900 for the performance of the work for which this permit Is jt ' Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF0 ER 19_ Lender s Name OWNER°AGENT 0000-0001 11/22/99C Lender s Address ADDRESS ��e E 3409 1 SAM 9:48 1 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 jaws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter Up e above mentioned property for Inspection purposes — 9,� SIg ture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE