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Home My Public Portal About9421 BROADWAY_Sewer__ CE80EZ9:BP APPLICATION FOR PE MIT •. COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL .� DEPARTMENT OF CO;$2.00 ENGINEER .Y. WILDING AND SADIVISION RU'ID 7 ttOT A, LAMBI£, 04*noor -0KSSATT D. GBIFFIN, of$uildinq LOCALITY NEAREST FOR APPLICANFILL IN CROSS ST. QL��T AL DESCRGP ION LOT NO. Jrii N OWNER MAILBLOCK TRACT � ADDRESS _NDGS. TSIZE OF LOT NOT / CITY / TEL. NO.OF BUE DINGS �� DISTRICT NO. GROUP IBK MAP PROCESSED BY CONTRACTOR, G 13ADDRESS _ CONNECTION DATA CITY T� TEL. .L � 6STATION DEPTH REGISTRATION NO. �{ "'y-7� SATE M 0 REFLOWER`DESCRIPTION OF WORKFEEHOUSE SEWER CONNECTING TOPULICSEWER@ $3.00 D a TYPE OF CONNECTION LENGTH FROMSEPTIC TANK,SEEPAGE PIT ORY. CURB P.L. M.L.TO P.L. PITS AND/OR DRAI N FIELD@ $3.00OVERFLOW SEEPAGE PIT.DRAINEXTN..CESSPOOL.DRYWELL $$2.00 HOUSE SEWER CONNECTING TO P.C.NO. PRIVATE 013Pn5AL SYSTEM @ $1.00 CO. IMP. NO. �-• JOB N0. CONNECT ADDITIONAL BLDG.OR WORK C HOUSE SEWER @ 81.00 TRUNK PERMIT NO. ROAD PERMIT NO. A LTE R.REPAIR OR ARAN 00N HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE lAL f oh I .HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. // TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THEPUBLICSEWER. SIGNED THIS IDA O 19_ NEW HOUSE SEWER - f�SDV' %1fF_IOAB OWNER OR - CONNECT ADDITIONAL. OWNERSAGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 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. ALTER,REPAIR, SEWER I HEREBY CERTIFY THAT I AM PROPERLY REG D AND/OR —SEWAGE SAL SYSTEM LICENSED IRED BY LOS ANGEL COON AND E OF DISCONNECTPLUGAND CALIFO IA OR T T I LE OWN OF E ABOVE ABANDON HOUSE SEWER DESCRI ED RESIDEN AL R P T , SECKFP;T(S SEPTIC TANKS ESSPO OS ❑ SIGNATU OF PERMI ®" ALIDATION RO ERT A. WOOD CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER (fir 1 4 1 12' ftAY ?'] 1 6 .D Q5�.0 0In / '°A642° APPLI ATION F PERMIT . ceeoe B.eu COUNTY OF LOS ANGELES ,L SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER S' -,BumamG AND SAFETY DIVISION ADDRESSG 67; a ]]ORT A. LAMBIE. County Engivasr q4PROCESSED CASSATTD. GRIFFIN, SupIof Buildiw LOCALITY �NEAREST FOR APPLICANTTOFILL INCROSSST.LEGALOWNER DESCRIPTION LOT NO.BLOCK TRACTI MAIL _, � ADRESSN OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OFBUILDINGS DISTRICT N0. GROUP MAP BK PG CONTRACTORADDRESS f CO INECTION DA CITY TEL.N0. G, STATION �- DEPTH . (/ /� �❑ TATE �ANP OLE @EF�ft ENCE V _♦ �A�p�� UPPER REGISTRATION N0. / �f3 �C_ — �4��lwIR (�r X��i I� iT UPPER NO. DESCRIPTION OF WORK FEE l v OUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 TYPE OF,CONNECTION LENGTH FROM PIETS AND/ORPTIC •DRAINFGIELDT OR @ S3.00 Y. CURB P.L. M.L.TO'.L. OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN..CESSPOOL. DRYWELL @ $2.00 C. HOUSE SEWER CONNECTING TO P. PRIVATE DISPOSAL SYSTEM @ 51.00 CO. IMP. NO. JOBBO. NNO. WORK TO CT HOUSE(SEWER LOG.OR. @ 51.00 TRUNK PERMITNO. ROAD PERMIT NO.� �S ALTER. REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. INDUSTRIAL r� WASTE APPROVAL �� CHARGES OWNERS PERMIT EL. CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE 1.1's REIMBURSEMENT FEE IHAVECON- T ACTORA TO CIONNECT THE ABOVE DESCRIBED EXIISTINGDATE A CONTRACT WITH THE HEREINAMED DWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS AY OF 19_ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL' OWNERS AGENT A 144 f BUILDING OR WORK ADDRESS- - SEPTIC TANK,SEEP. PIT(S) AND/OR DRAINFIELD I HEREBY ACK WLEDGE THAT I HAVE READ THIS APPLICATION " ANO STATE THAT THE ABOVE. IS CORRECT AND AGREE TOCOMPLYCESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. ALTER.REPAIR,SEWER OR SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPER RE ERED D/OR DISCONNECT PLUG AND LICENSED AS REQUIRED LOS NGEL COU Y AND TATE OF ABANDON HOUSE SEWER CALIF R THAT A LE OW ER OF HE ABOVE DESC BED RE ENT! P OP T . BACKFILL SEPTIC TANKS ❑ SIGNA E SEEP. PIT(S) ❑ CESSPOOLS OF PERM JOB / ®r /VALIDATION RE T A. WOOD M.0. usH SUPERVISING OB MECHANICAL ENGINEER LU1412o MY27 1 1 G 25 .00 n WORKERS'COMPENSATION DECLARATION . I hereby affirm that I have o certificate of consent to self 92'0002 DPW 3/87 A A >6Ae<RD IR , ,L IIS insure, or a certificate of Workers'Compensation Insurance, or CE FEE- ' a certified copy thereof (Sec.,3800, Lab C.) APPLICATION' FOR PERMIT Policy No. ' Company ®s .. - ' ❑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' BUimwG ••77 COMPENSATION INSURANCE ADORESS ps STATION DEPTH (This section need not be completed if the work involved by the U permit is}or one hundred dollars ($100)or less.) LOCALITY („, AV NHOLE REFERENCE O R NEAREST TYPE OF CONNECTION certifytbdt in the performance of the work for which this - LENGTH FROM - ? CRO55 T. VZj- ✓ (o permit is issued,1 shall not employ any person in anyYCURB PA, M.L.TO P.L.Y.manner ' so ds to become subject to the Workers' Compensation Laws. /O P p 'h.y/ - P.C.NO. , OWNER I I��V/F I v CO:IMP,NO. JOB NO. MAII Date Applicant ADDRESS /[• n/ y!1)A(1tU TRUNK PERMIT NO. ROAD PERMIT NO. - NOTICE TO APPLICANT: If,• after making, this Certificate of. AFFIDAVIT W41WR EASEMENt RECORD.wsTR.No. DATE Cn! �, .TEL.NO. ab'G6.3 3 Exemption, you ,should become subject. to the. Workers' LEGAL Compensation provisions of the Labor code; you must forthwith DESCRIPTION LOT NO. HWY.OR Si.WIDENING comply with such provisions or this permit shall be deemed - - revoked. - BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.Of BLOGS. - - PERMIT NO. SIZE OF LOT NOW ON LOT I.hereby affirm that 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 CONNECTION CHARGE FEE y License Number L10.Ca55 ADDRESS REIMBURSEMENT FEE d COatIOCIO( Date DISTRICT NO. GROUP MAP PROCESSED By V CITY TEL NO. ❑ I am exempt under Sec. of the L.A.Co. STATE BK PG o LICENSE NO. EE /t '1 0 Plumbing Code and/or Se{ of the NO: DESCRIPTION OF WORK FEE FINAL O` U t HOUSE SEWER CONNECTING TO DATE W B. E,P. Code:for the following reason PUBLIC SEWER ' VALIDATION a SEPTIC TANK,SEEPAGE PIT OR ! H Dale PITS AND/OR DRAINFIELD FINAL _ Z HOUSE SEWER CONNECTING TO BY , PRIVATE DISPOSAL SYSTEM �ry •� Signature CONNECT ADDITIONAL BLDG.OR ' _ OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD m707 IIIc I hereby affirm that I am exempt from the Contractor's License EXTN..CESSPOOL,DRYWEU,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER.REPAIR OR ABANDON HOUSE Tessio ode): SEWER OR DISPOSAL SYSTEM I,as owner of the property,or my employees with wages as —til=l.te i their sole compensation, will do the work and the structure _ is not intended or Offered for sale (Section 7044, Business 7 ' and Professions Code). OWNER'S - Permit .$ a 4'n ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATIONI TOTAL FEE licensed contractors to construct the project (Section 7044, I HAVE AT THIS.DATE A CONTRACT.WITH THE HEREIN NAMEDCONTRACTOR TO Business and Prafesslons Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, CONSTRUCTION LENDING AGENCY I _ hereby affirm that there is a construction lending agency SIGNED THIS DAV OF 19_ - - - for the, performance of the work for which this permit is OWNER OR , 1I1 ik -11 . 75 _ issued (Sec. 3097, Civ. C.). OWNERS AGENT rICr�f - -1- Lender's.Nome - ADDRESS �. 1`: Lender's Address _. '. CHrii'G ,(;I 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 StaWninspection Plumbing and Sewers, and reby t jf this County to.enter upa-m purposes. - l'd'`'T. i Ail Signature" P rmittee Date _ SEE REVERSE FOR EXPLANATORY LANGUAGE