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Home My Public Portal About9321 BLACKLEY ST_Sewer__ r 76A64213 S&E-669 11.55 APPLICATION FOR PERMIT IT DIVISION OF BUILDING AND-SAFETY SEWER-SEWAGE DISPOSAL Department of County Engineer County of LoL es BUILDING JOHN A. LAMBIE, CENGINEER ADDRESS ® CASSATT D. GRIFFIN, F BUILDING LOCALITY / NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL OWNER DESCRIPTION LOT N0. � a' �^ MAILYAR - BLOCK •3CJ TRACT ADDRESS O. OF BLDGS.' CITY TEL. NO. SIZE OF LOT NOW ON LOT s USE OF - DISTRICT NO.• GROUP MAP BUILDINGS � I BK PG CONTRACTOR CONNECTION DATA ADDRESS STATION DEPTH ��. -' CITY TEL. NO. S� ,�,��COUNTY MANHOLE REFERENCE PPER V REGISTRATION NO. ❑ COUNTY - NO. . DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF URyyECT10N LENGTH FROM IkPUBLIC SEWER @ $3.50 Y. CUR P.L. M.L. TO P.L. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD a $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD �/ C. NO. CO. IMP. N0. JOB NO. EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 A HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Q $1,00 TRUNK PERMIT NO. ROAD PERMIT N0. _ °{ CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT , WORK TO HOUSE SEWER t@i $1.00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM nl $1.00 WASTE APPROVAL CHARGES _ CONNECTION CHARGE FEE OWNER'S PERMIT $ 1 00 - AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- APPROVALS DATE_ INSPECTORS SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. p. NEW HOUSE SEWER SIGNED THIS `'!.` DAY OF 19 CONNECT ADDITIONAL OWNER ORBUILDING OR WORK OWNERS AGENT SEPTIC TANK,SEEP,PIT(S) ADDRESS § aa` '4e�ft� 2F"�-o AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP ICATION CESSPOOL❑ DRYWELL❑ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY - WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LAOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER �DCRIBr IFORNIA 0 THAT N1 THE GAL OWNER OF TH A REST P�T� i;ERTY. KFILL SEPTIC TANKS❑Y P. PIT(S)'❑ CESSPOOLS P PERM ITT JOHN A. LAMBIE, COUN ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR CK. Id.0. hj� Agri - 21 A - _ -4 0 - . WORKERS'COMPENSATION DECLARATION I hereby affirm that I have g cer(ifi;;p a c;4-consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A6420 a certified 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 �j STATION DEPTH COMPENSATION INSURANCE ADDREss (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 LOWER I certify that in the performance Of the work for which this CROSS NEARESST. TYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ any person in any manner Y cuaB P.L. M.L.TO P.L. so.as to become subject to the Workers'Compensation Laws. P.B NO. OWNER,_ CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE, TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT . LICENSED CONTRACTORS DECLARATION NOOF BLDGS. PERMIT NO.SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR A CONNECTION CHARGE FEE License Number LIC.Class ADDRESS ` REIMBURSEMENT FEE Contractor Date CITY TEL.NO. 1 , ' DISTRICT NO. GROUP MAP ROC�SjSTATE (' L ( :(i,r` IIC. BK PG❑ I am exempt under Sec. of the L.A.Co. LICENSE No. o+. ` �� CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATI N f0) HOUSE SEWER CONNECTING TO AA KT D B. & P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FIN e Date HOUSE SEWER CONNECTING TO BY //�} PRIVATE DISPOSAL SYSTEM � { /.I 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 SEEPAGE PIT,DRAINFIELDEXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ! fessions Cade): SEWER OR DISPOSAL SYSTEM F-1 1,as owner of the property,or my employees with wages as ACCT, their sole compensation, will do the work and the structure 3307 3r},,,j;,i is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit S 1 ITEMS El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL iTAL 34 o 50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED NTRACTITOBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. C iCONSTRUCTION LENDING AGENCY � EC�Y � �_L)�I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1CHANGE .00 for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT Lender's Name ADDRESS 13130Q_)0,0Q1 5/30 90 Lender's Address 0997 1 Ali 9:54 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, Aonnd.hereby authorize representatives of this County to enter the ab -mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE