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Home My Public Portal About9162 BROADWAY_Sewer__ C E80B 10-63x 76A642D APPLICATION FOR PERMIT 1 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION r eu ILOING JOHN A. LAMBIE, County Enginee WILLIAM A. IENSEN, Supt of Building LOCPLiTY NEAREST � FOR `1�J��PLI ANT TO FILL IN `Ross sr. LEGAL T �/ DESCRIPTION LUT NO. 3 R BLOCK TRACT —7 -719 T ADDRESS NO. OF BLOGS. / SIZE OF LOT NOW ON LDT CITY TEL. NO, USE OF BUIDINGB BPG DISTRICT NO. GROUP MAP PROCESSED BY USE OI _ ,AK CONTRACTOR/I /I 5 L /-/ ADDRESS �f- J �L CONNECTION DATA /5 STATION / T DEPTH /1 CITY VTi REGISTRATION NO. COUNTY MANHOLE REFERENCE OWER NO. DESCRIPTION OF WORK EE TYPE OFC ECTION vCJLENGTH FROM HOUSE SEWER CONNECTING TO - - Y. CUR P.L. M.L.TO P.L. r PUBLIC SEWER $5.00 - SEPTIC TaNN.SEEPAGE PIT OR j "�'�j P.C.NO. d PITS AND/OR GRAINFIELD ® 310.00 CO. IMP. NO. I J / lOB NO. 0 �I HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N PRIVATE DISPOSAL SYSTEM 33.00 O K I CONNECT ADDITIONAL BLOC,OR AFFIDAVIT nry ss[K[xi RECORD.INSTR.NO, DATE 0 WORK TO HOUSE SEWER ® S3.00 F� OVERFLOW SEEPAGE PIT,DRAINFIELD U EXTN..CESSPOOL.DRY WELL.MAN H OLE® $5.00 W ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N SEWER OR DISPOSAL SYSTEM ® 33.00 STATE ENCROACHMENT Z PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ z 00 AUTHORIZATION TOTAL FEE L CONNECTION CHARGE FEE CHARGES T HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS URE TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNAT SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK.SEEP,PITIE) IH ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSALSYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER .. AND INT E NO TO DISCONNECT PLUG AND RESIDE IN, THE a VE EBCRIBEO_pE51$ENTI PROPER ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE JI BACKFI LL SEPTIC TANKS ❑ SEEP.PIT IS) ❑ CESSPOOLS ❑ VALIDATION ROBERT WOOD CKKU. M.D. CASH SUPERVISING MECHANICAL ENGINEER I (A'u'0 3 9 6 2 SEP 18 1 0 D 7.00— r21) -°2 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUIADDRLESIN ViO //� JOHN A. LAMBIE, County Engineer "� WILLIAM A. IENSEN, Supt of Building J LOCALITY / ! "-�'c�'� �!} NEAREST / / FOR APPLICANT TO FILL IN CRDSB 5T. r LEGAL A� DESCRIPTION LOTNO. IO OWNER GL OF BLOCK /'TRACTAODRESB�,I TIG O �� NOW ON LOT 512E OF LOSLOGS. / CITY VrGL _ TEL. NO. USE OF BUILDINGS �1./y/ �L.z-� DIISST.ICT N(OO. GROUP MAP /' [/PPR'OICESSED BY INK PG CONTRACTOR , 1` L-yJ T fJ/ DQ L M- ( !� �( �l ADDRESS ' 7Q 0 4 a-( CONNECTION DATA CITY TEL. NO. 5N10 N DEPTH STATE UPPER REGISTRATION NO. COUNTY MA.110 FERENCE LOWER NO. DESCRIPTION OF WORK FEE TYPE OF E_CTION LENGTH OM IL HOUSESEW ERICONN ECTING TO Y, CUR P.L. a PUBLIC SEW ER 55.00 O SEPTIC TANK,SEEPAGE PIT OEt PITS ANO/OR GRAINFIELD SIO.Do CO.IMP. NO. JO O. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. GAD PERMIT NO. O PRIVATE DISPOSAL SYSTEM E9.00 F CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVERASE ENT ECO INSTR.NO. DATE W WORK TO HOUSE SEWER ® S3.00 I a OVERFLOW SEEPAGE PIT,GRAINFIELD UO EXTN..CESSPOOL.DRYWELL.MAN H OLEO SS.00 Z S1eeE=V=gSLISPOSAL SYSTEM ® $3.00 STATE ENC ROAC ENT PERMIT NO. NOUSTRIA WASTEA ROVAI OWNER'S PERMIT $ 2 OO CHARGES AUTHORIZATION TOTAL FEE S'I� CNECTION CHARGE FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR5 SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK.SEEP,PIT(5) IIT ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/OR GRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAI R.SEWER OR LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AM THE LEGAL OWNER F, AND INTEND TO PISCO NNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBEENTPBRT . ABANDON HOUSE SEW ER 1 SIGNATURE 'k BACKFILL SEPTIC TANKB ❑ I' OF PERMITTEE SEEP.PIT ISI ❑ CESSPOOLS ❑ V �7ALIDATION ROBERT WOOD M.0. CASH SUPERVISING MECHANICAL ENGINEER 5.0 0" 2 4 3 7Z AUG 1 1 1 0 D Q v. WORKERS' COMPENSATIOI1 DECLARATION I'hereby affirm that I have a certificate of consent to self S"I insure, or o certificote of Workers"Compensation Insurance, or 16Ae42D U a certified copy thereof(Sec. 3800, Lab C.) CE BDB(REV.Ulu) APPLICATION p PP8 Oda.A y�O®fin ®R PER�IT Policy No. Company A �L�pI�sA 0 �p�0p�1/� p ❑ Certified copy is hereby furnished. tL , SEWER - SEWAGE DISPOSAL Certified copy.is filed with the county building.inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Dote AppU<pm t FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING - COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the /J UPPER permit is for one hundred dollars ($100)or less.) LOCALITY C. MANHOLE REFERENCE LOVER I certify that in the performance of the work for which this NEAREST Y. CURB Pit ML.TO P1. TYPE OF CONNECTION - LENGTH FROM . . permit is issued, I shall not employ any person in any manner so as to become subject to the Workers"Compensation Laws. OWNER C� CO.IMP.NO. JOB NO. MAIL C-/ TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicont ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of CITY d, . �/. AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE TEL.NO. Gj Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO, HVVY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No.OF BLOGS. PERMIT NOI. . SIZE OF LOT NOW ON LOT 9 (co by affirm That I am licensed under provisions of Chapter . USE OF 9 (commencing with Section 7000) of Division 3'of the Bulli- - BUILDINGS- -- - - _-- - _ _ CHARGES ness and Professions Code, and my license is in full force and -` - -- - --- - - effect. _ CONTRACTORR //// /+ CONNECTION CHARGE FEE License Number SD Lic.Class ADDRESS l '� J REIMBURSEMENT FEE DISTRICT NO. GROUP MAP' PROCESSED BY Its. Contractor .J Dafen `i�y�J � CITY TEL NO. F�R�D ^WSS O ,A LIC V El am exempt under Sec. of the L.A:Co. STATE BK PGLICENSE NO. V CLASS 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO FINA �] (7 VALIDATION e7 B. 8 P. Code for the following reason PUBLIC SEWER �Z�/"'d E W SEPTIC TANK.SEEPAGE LPITD OR FINAL ! G PITS AND/OR SEEPAGE IELD ��e,Rr y Dale HOUSE SEWER CONNECTING TO BY cJ� Z PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR D OWNER-BUILDER DECLARATION � WORK TO HOUSE SEWER -� I hereby affirm that I am exempt from the COntractar's License OVERFLOWs oaGoerwcuAm FIELD Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER.REPAIR OR ABANDON HOUSE fessiOnS Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as S,4 3 8 1 A their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit E I ' e ❑ I, owner of the property ,am exclusively contracting with AUTHORIZATION TOTAL FEE t ,2�. Io 21.50 licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CO RACTOR TO e.o ^ 21-50 p Business and PFOfeBBiODS Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1 CONSTRUCTION LENDING AGENCY 2 D 0,9, Q-8 Q , I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR ' issued (Sec. 3097, Civ. C.). OWNERS AGENT Lenders Name ADDRE55 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 10 enter upon r e oloove-mention prd erf or inspection purpose nature of Permieee ' Date SEE REVERSE FOR EXPLANATORY LANGUAGE