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HomeMy Public PortalAbout9451 BROADWAY_Sewer__ DEPARTMENT OF COUNTY ENGINEER ' y SEWER-SEWAGE DISPOSAL y DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER I ADDBUILRDIESSNG /J LOCALITY FQ �PLIC�1T FILC +7i n A_- fi 740 • ADDRBUILDESS �yJ "" NEAREST A A00 KESS CROSS ST. p //r-, LOCALITY � — DISTRICT N0. SERIAL NO. PERMIT NO, NEAREST s 145 kf9 G 4f1 S CROSS ST. }R�ECEIVED BY Ready for Inapectloo .1 DATE ISSUED OWNER MAIL ADDRESSUSE ZONE a OCCUPANCY MAP BK PG CITY I TEL.NO J G/LAG/ CONTRACTORCO.IMP.NO. M- 1 L 2 ADDRESS / JO N0. CITY TEL.NO. G TRUNK PERMIT NO. STATE REGISTRATION NO. J w e COUNTY g0A0 PERMIT N0. / LEGAL a DESCRIPTION LOT N0. �rI STATEENC90ACHMENT PERMITNO. \ B181B1( TRACT �+f0 INDUSTRIAL \ OOti Ec-.IC UJtL +>_: WASTE APPROVAL SrPBOF-hOTNQ.Of-BteGS. N "i�TJ CHARGES USOF BUIL DINGS CONNECTION CHARGE F E\ / NO. DESCRIPTION OF WORK FEE t HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE / PUBLICSEWER @ $ 3.50 RECEIPT NO. I /`DA\ I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 / CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO HOUSE BE 1.00 ALTER OR REPAIR EXISTING NO- I/ DATE \IBY SEWER OR DISPO SALSYSTEM 1.00 ` AND/OR IS AND ABANDON SEWER ,CONNECTION DATA AND/OR ECT AN DISPOSAL SYSTEM 1.00 SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAIN 2.00 STATION / DEPTH \ CESSPOOL-DRV W ELL SPECIAL CONDITIONS ONLY 2.00 / MANHOLE REFERENCE \ UPPER LOWER TYPE OFCONNECTION LENGTH FROM \ r OWNERS PERMIT $ 1 00 Y. CURB P.L. M.L.TO P.L. AUTHORIZATION TOTAL FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED HAVE TO CONNECT THE-ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER .7 SIGNED THIS.-_-ti. .-.-.D Y OF... ... .................... NEW HOUSE SEWER OWNER OR r-- CONNECT ADDITIONAL 0 f OWNERS AGENT..... .. .._ . . j BUILDING OR WORK - ADDRESS..... F. LI SEPTIC TANK,SEEP.PIT(S) ----' (S --:'- -- - -- -C�- ---- AND/OR IRAINFI ELD i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL E] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND ANO/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM E LEGAL OWN- ABANDON HOUSE SEWER ER OF THE ABOVE DE IBED RESIDE L PROPERTY; BACKFILL SEPTIC TANKS SEEP.PIT(S)E] CESSPOOLS SIGNATURE OF PERMITTEE... . ...- ....tiy..... ... ..LF`_..L.--- --- ------ 28A642D 663, 1/53 , � e C 76A 642D'`CEB08 A-7/76 APPLICATION FORERMIT SEWER—SEWAGE DISPPOSAL COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION - DISTRICT ND. GROUP MAP ES BY FOUR APPLICANT TO FILL IN �BK� PG p ADDRESS b, / LOCALITY =i( f.0 _ Ci CONNECTION DAT NEAREST $TA%fON DEPTH CROSS ST. MA OLE REFERENCE UPPER C LOWER OWNER - YPE OF CONNECTION LENGTH FROM MAIL Y. CURB P.L. M.L.TO P.L. ADDRESS P.C.NO CO.IMP. NO. JOB NO., CITY � NO, LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. pESCRIPTION LCT NO. - �. AFFIDAVIT [rv{[ u5[N[RT RECORD.INSTR.Nq GATE BLOCK TRACT /% �— v NO. OF SLOGS. SIZE OF LOT NOW ON LOT _ _ _ HWY.OR ST,WIDENING USE OF BUILDINGS STATE ENCROACHMENT �J .PERMIT NO. / /� TT CONTRACTORMOM �� f- IL ,((G INDUSTRIAL QUNC, I– a �T C WASTE APPROVAL ADDRESS O h V O GQn' iF�O - CHARGES Q CONNECTION CHARGE FEE U CITU � TEL. NO.� -2L Z[(U OA. STATE _ LIC / , A REIMBURSEMENT FEE LICENSE NO. GLA NO. DE$ RIPTIO F O K FEE APPROVALS DATE INSPECTOR'5 SIGNATURE W HOUSE SEWER CONNECTING TO a PUBLICSEWER ® (n SEPTIC I'ANK.SEEPAGE PIT OR NEW HOUSE SEWER Z PITS AND/OR ORAINFIELID CONNECTADDITIONAL '] HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM Q SEPTIC TANK,SEEP.PITIS) CONNECT ADDITIONAL BLDG.OR / AND/OR GRAINFIELD WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL ❑ EXTN..CESSPOOL.DRYWELL.M>NHOL[ ALTER,REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM ® SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS ❑ SEEP.PITISI [ICESSPOOLS ❑ . OWNER"S Issuance Fee s AUTHORIZATION TOTAL FEE I HEREBY ACKNOWLEDGEABO THAT HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IE CORRECT AND AGREE E COMPLY BIPPWITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON pIU HE;R AND SEWERS. TR4CTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR TO THE PV ELIC SEWER. LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SIGNED THIS DAY OF IJ_ CALIFORNIA OR THAT I AM THE LEGAL OWN OF, AND INTEND TO OWNER OR RESIDE IN,'THE ABOVE OE IBED RESIDE AL PROPERTY. OWNERS AGENT • SIGNATURE �. OF PERMRTEE WORKERS COMPENSAT vALIDATIo M D CASH POLICY HOLDER: 1 �� L L�� ' � taY 22 1 0 o 2 1.0 0 AM POLICY NUMBER: fC �5°U 17i/3 CEBUR 10-fi3 APPLICATION �PERW E80 1 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION, Ba ILDING JOHN A. LAMBIE. County Engineer ADDRESS WILLIAM A. JENSEN, Supt of Building LOCALITY NEAREST FOR APPLICANT T FILL IN CROSS ST. LEGAL DESCRIPTION LOTNO. �n OWNER MAIL BLOCK TRACT ADDRESS NO. OF SLOGS. SI2E OF LOT NOW ON LOT CITY /• TEL. NO. B SELDINGS �/ -- DISTflI TND. GR MAP PROCESSED BY PG CONTRACTO �j l ©�� BK � �� ADDRESS _/// (/ Sf CONNECTION DATA ir / STATION ` O O DEPTH CIT TEL. NO. J ST TE UPPER REGISTRATION NO. COUNTY MANHOLE REFERENCE LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. Y PUBLIC SEWER 55.00 4• SEPTIC TANK,SEEPAGE PIT OR �l POB N 11C - ST O PITS ANO/OR DRAINFIELD 310.00 P.NO. ,J� L V HOUS CO.IME SEWER CONNECTING TO I TRUNK PERMIT NO. ROADPERMIT NO, IVp[ PRATE DISPOSAL SYSTEM ® 53.00 0 CONNECT AO iQVA G.OR D� AFFIDAVIT WVIII. EAS[X[XT RECORD,INSTR.NO. DATE r DRK TO HOUSE SEWER 33.00 U OVERFLOW SEEPAGE PIT.DRAINFIELD W EXTN.,CESSPOOL,DRYWELL.MANHOLE $3.00 CC ALTER,REPAIR ON ABANDON HOUSE H'NY,OR ST.WIDENING N SEWER OR DISPOSAL SYSTEM ® 33.00 STATE ENCROACHMENT PERMIT NO. J INDUSTRIAL _ :r WASTE APPROVAL CHARGES OWNER'SPERMIT s z o0 AUTHORIZATi6N I TOTAL FEE A CONNECTION CHARGE FEE '1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. DATE INSPECTO 'SSIGNATURE SIGNED THIS DAV OF 19_ OWNER OR NEW HOUSE SEWER OWNERS ADEN CONNECT ADDITIONAL � ADDRESS BUILDING OR WORK _<_ T SEPTIC TANK,SEEP. PIT IS 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AVO/OR DRAINFIELD ANO STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEW ERS. CESSPOOL ❑ DRYWELL ❑ 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR A-TER,REPAIR,S EWER OR LICENSED AS REOUI D BY LOS ANGLES COUNTY AND STATE OF SEW AGE DISPOSAL SYSTEM CALIFORNIA OR TH A E LEGAL OWNER OF, AND INTENp TO RESIDE IN. THE A E RIBED RESIDENTIAL PROPERTY. DISCONNECT PLUG ANO ABANDON HOUSE SEWER SIOF APER TURETT _jjBACKFILLSEPLLJTAN K S ❑ 1 /- SEEP, PIT ISILO' CESSPOOLS ❑.V1 /Z VALIDATION--:7:) --� ROBERT X WOOD CK, M.O� CASH J S'PERVISING MECHANICAL ENGINEER L;O7 8 9 3% APR 4 1 0 D 5.00~ WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 20'0051 DPW SEE insure, or a certificate of Workers' Comp nsatlon Insurance, or 76AB42D a Policy No L hereof ISec 38 La .) c APPLICATION FOR PERMIT Pohc No Compon ❑ Certified Copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deport em, r Dole Z Applim^t FOR APPLICANT TO FILL IN CONNECTION DATA CERT FICATE OF EXEMPTION FIRM WORKERS' auILDwG �" COMPENSATION INSU ANCE ADDRESS P STATION DEPTH (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 MANHOLE certifyThat in The performance of the work far which this NEAREST - 1VPf OF CONNECTION LENGTH FROM P CROSS ST. Z V CURB P L M l TO P L permit 's 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 Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after makin this Certificate o{ ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO. DATE 9 MAP BOOK PAGE - PARCEL Exemption, you should become subject to the Workers' Compensation provisions of the Labor code, you must forthwith NO.OF BLDGS. p p y SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. - BUILDINGS STATE ENCROACHMENT f LICENSED CONTRACTORS DECLARATIONPERMIT NO I hereby affirm that I am licensed under provisions of Chapter owNE 9 (commencing with,Section 7000) of. Division 3 of the Busl__. MAIL ness and Professions Code, and my license is in full force and ADDRESS - S �... _ _ _ CHAR E effect. / CIT S I I iEL.NO. CONNECT,O E FEE license Numb r LID.Class �4 b - RD.vauRS ENT FEE CONTRACTOR N ' COnlraCta! fJ Pl)Date < „ .O � � \\ DISTRICT NO GROUP MAP PROCESSED BY ADDRESS �I WCX.X- 1 Bx PG ❑ I am exempt under Sec. of the L.A.Co. 1 (� -> (/ 0- p C Yrc TEL N0310 'S _J`OQ a' 0 Plumbing Code and/or Sec. of the STATE uC. zY _ ? FINAL - p LICENSE NO. CLASS k-'. -] DATE 7 6 VALIDATION Z B. 14 P. Code for the following reason NO. DESCRIPTION OF WORK FEE / _ / — ( Q HOUSE SEWER CONNECTING TO FINAL F Date UBUC SEWER B E.1 SEPTIC TANK SEEPAGE PIT OR W PITS AND OR DRAW FIELD D. Signature OWNERBUILDERDECLARATION HouAT sCONNECTING To - PRIVATE DISPOSAL SYSTEM Z I hereby affirm that I re exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the followingreason Season 7031.5. Buisness and Pro- WORK 70HOUSE SEWER fessians Code): ( EXIN Ow SEEPAGE OOL.DPN ELL.MANN _ _ - �"f�1 fO�'•Idl1 E%iN.Cfs$PWLDRVWELL.MANHOLE { Ll 1,1,as owner of the property, of my employees with wages as ALTER,REPAIR OR ABANDON MOUSE ITEMS I'J SEWER O DISPOSAL SYSTEM _ their sole compensation,dedorfer will do the work and the Business _ is not intended or offered for sole (Section 7044, Business jLllt�L 154 - 00 and Professions Code). CHECK 1.74.0171 ❑ 1,as owner of the property,am exclusively contracting with $ M` licensed contractors to construct the project (Section 7044 Permit OWNER'S CHH( }E .130 Business and Professions Code). AUTHORIZATION TOTAL FEE PD ` CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO r ('�r1 4/2-YKI V I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DAEUING TO THE PUBLIC STIED UOOLI—CIUUI 4/ for the performance of the work for which this permit is 9- ,� ,�- issued (Sec. 3097, Civ. C.). SIGNED THIS DAY F�' 19� TJ22 I AN T'-1+ OWNER OR ' Lender's Name OWNFR5 AGIN1 -N"� Lender's Address DDRE$$ I certify that I have read this application and slate that the above information is correct. I agree to comply with 011 County ordinances and Stole laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon a abovementioned operty of in$ peal n pur ores. ' yjz� Signatur r f Permittee Dcillb SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION 200051 DPW 6189 I hereby affirm that I have a certificate of consent to self z6A642D LLLIII Insure, or a certificate of Workers'Compensation Insurance, o a ceni}ie ,$.o�P�a t7h real I 800, b C.)' A fmf�A ITP' A TMN FOR PERMIT Policy Nri ll, zm_Cbr�,p ny� 7C� /� i"i1r51[E ILWE'sRb`h-1 YSEWAGE DYI'ISPIrOL:SII'cA9HlB Certified copy is hereby furnished. Certified copy is filed with th county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY dBiparimeni. APplic°nt- FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING - J COMPENSATION INSURANCE ADDRESS ` STATION DEPTH (This section need not be completed if the work involved by the ! MANHOLE REFERENCE - UPPER permit is for one hundred dollars ($100)or less.) LOCALITY l LOWER NEAREST � TYPE OF CONNECTION UNGTH FROM I certify that in the performance of the work for which this CROSS ST. (//j/ Y CURB PL MI'TO PL permit is issued, I shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO, CO IMP NO JOB NO Date Applicant BLOCK TRACT IPUNK PERMIT NO ROAD PERMIT NO ASSESSOR (/ (J AFFIDAVIT WAIVER EASEMENT RECORD IN$TP NO DATE NOTICE TO APPLICANT: If, offer making This Certificate of MAPBOOK - Q a PAGE _L�� PARCEL Exemption, you should become subject to the Workers' Compensation provisions Of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT NO.OF BLDG$. HWv 045i WIDENING comply with such provisions or this .permit shall be deemed USE of revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION P RMIT NO '/G � hereby affirm That am licensed under provisions of Chapter OWNERSi CAA-4 9 (commencing with Section 7000) of Division 3 of The Busi- MAIL - > ADDRESS. _ CHARGES y ness and Professions Code, and mlicense is in full force and - - - effect. CITY TEL NO, CONNECTION CHARGE FEE ❑CCnsC NUm6C✓ V�LiC COSS l-/:3 IY � / -7- REIMBURSEMENT LEE � M(L�^ — I,�F��/^. CONTRACTOR / Lv COn VaCIO'."1_y/./y EIFVI !' /IfJ'`'� DISTRICT NO GROUP MAP PROCESSED BY l ' , ADDRESS 8K PG } ❑ l am exempt under Sec. of the L.A.Co. CITT j iEL.NO, � � a Plumbing Code and/or Sec. of the STnTE LG O FINAL yyy��( O LICENSE NO. / CLAS DATE �f � VALIDATION Z B. 8 P. Code for the following reason NO. 1 DESCRIPTION OF WORK FEE �C Q MOUSE SEWER CONNECTING TO FINAL Date -PUBLIC SEWER By /V/y 7L SEPTIC TANK SEEPAGE PIT OR OF 5ignotur� /�/O//n PITS AND OR DRAINLIEID { N G LUrf6 . 1 O NER-BUILDER DECLARATION HOUSE SEWER CONNECTING 10PRIVATE DISPOSAL SYSTEM D I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BDG OR f. i WORK TO HOUSE SEWER' Law for the following reason (5e<tOn 7031.5. BviBne55 and Pro- OVERFLOW SEEPAGE PIT DRAwLIELD fessions Code): ��[17 E%IN CESSPp'JL DRYWELI.MANHOLE 54.:51yI ALTER,REPAIR OR ABANDON HOUSE i ITEMS i� ❑ I,Their owner of the property,will o employees with wages as SEWER OR D6PGSAL SYSTEM 1 1 Their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business TOTAL 59 - 30 and Professions Code). \, ElI� I,as owner of the property, am exclusively contracting with � / �ELCHECKc.9. licensed Contractors to construct The.project (Section 7044, OWNER'S Permit $ `p CHANGE .DLI Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction' lending agency CONNECT THE ABOVE DESCRIBED TESTING DWELLING TO THE PUBLIC SEWER for the performance of the work for which this permit Is D 171 I ! - I I] _YiCV93 issued (Sec. 3097, Civ..C.). SIGNED THIS_DAY OF 19_ Lender's Nome o NFR50AGENT 5601 1 Art 11:54 Lender's Address 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 Slate laws regulating Plumbing and Sewers, and hereby authorize representatives of This County to enter upon ke above-me t of property for 'nspElction purposes Signature of Permittee D le L� SEE REVERSE FOR EXPLANATORY LANGUAGE r Fl