HomeMy Public PortalAbout9628 1/2 BROADWAY_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
l;.VISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
" WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT TO FILL IN' LOCALITYBUILDING
ADDRESS CROSS STNEAREST. C. 15L V,/-7
LOCALITYI „yy� (=.�(y (/ DISTRICT N0. SERIAL NO. PERMIT N0. r
NEAREST t�,� / ../ / A "fXa-"r S
CROSS ST .rOe..,,�Ep C:_.Lyy RECEIVED'L,QBV Reedy for Inspection OATSUEO
OWNERG///. p�,jo�C�.LMIL.dE'�v /�/// -,2Y-��/
MA(')L —Sy/�Le �O ' C �j USE ZONE OCCUPANCY BK MAP PG[/
CITY cid TEL.NO.� � l U;&- —r,P,OO ��i �1 /
CONTRACTOR, '�L�O_L� ,�� CO.IMP.NO. JX 7 G R-Z
ADDRESS JOB.NO. .---- �
CITY G'h TEL.NO.,k,�l STATE❑�'J,? TRUNK PERMIT NO.
REGISTRATION NO. //_3 —B=COUH7Vq //
LEGAL ,{ ,J �j PERMIT N0.ROAD PERMIT N0. .2 7 Ife 2 7 7
. 44�6f )
STATE ENCROACHMENT
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DESCRIPTION LOT ND. (f �
BLOCK TRACT -;J�/ l�e.., USTn... RIAL
kIWN,AOSTE APPROVAL
SIZE OF LOT NO.OF BLDG$. CHARGES
NOW ON LOT 7
USE OF
��
BUILDINGS V i/'/c.lj •�•t/J n/In/. CONNECTION'G RGE FEE
NO. DESCRIPTION OF WORK FEE
/ HOUSE SEWER CONNECTING TO ,r— REIMBURSEMENT FEE
_ PUBLIC SEWER 0 $ 3.50 :J 0 RECEIPT NO. BV
HOUSE SEWER CONNECTING TO
PRIVATEDISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPT[ON RECORDED
WORK TO HOUSE SEWER 1.00 C7 G+ NO.
ALTER OR REPAIR EXISTING DATE BY
SEWER OR DISPOSAL SYSTEM 1.00 _
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION / (J�..1DEPTH 6
CESSPOOL—DRVWELL / MANHOLE REFERENCE
SPECIAL CONDITIONS ONLY 2.00 Yr'35;� Dr aPSLR LOWER
TYPE OF CONNECTION LENGTH FROM y /
OWNERS PERMIT S 00 Y. CURB i P.L. M.L.TO P.L.
AUTHORIZATION-- TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS P ECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
ii /
SIGNED THIS.._1Z-__...._...DAY OF..tiL.UNE -____-_—,. IqS�! NEWHOUSESEWER
CONNECT ADDITIONAL
OWNER OR �(,Q �,�� _ BUILDING OR WORK
OWNERS AGENT,........._......_......_!S`::--'.._.:.:..__._.._.._.
Lq 4ST oAD WA TE PLC LITS SEPTIC TANK,SEEP.PIT(S)
ADDRESS.q_..I+.LP...�.._.._..JJ...Y...._.._.._.._.rl__.._H_._.�_...._._.. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL E] DRYWELL 0
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
I HEREBY CERTIFY THAT IAM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON"OUSESEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E
SIGNATURE ��V SEEP.PIT(S)� CESSPOOLS
OF PERMITTE
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