HomeMy Public PortalAbout9968 BROADWAY_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING ADDRESS /9/?O,40
ADDRESS
FOR APPLIC NT O FILL IN LOCALITY 1G,
BUILDING Q //' NEAREST
ADDRESS / KJLL CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST /CRO55ST. 4 /7 AlAA 5� A 3C Y-y s
RECEIVED
-BY- I Ready for Inspection DATEISSUUEED
/M+�/
OWNER / .-'J ^f' J sE
MAIL =S Ct. USE ZONE OCCUPANCY MAP
ADDRESS
BK PG
CITY ��pTELNO.
CONTRACTOR / yry jy .�J)"'/j�P�f �y//,(.�f/; CO.IMP.NO. Z7 G p /�
ADDRESS �/`� .��/ w-I lr` •JOB.NO.
CITY rp / TEL.NO. TH 22/2 TRUNK PERMIT NO.
J LL FP4 PI STATE
REGISTRATION NO. +/ J� ? ❑ COUNTY ROAD PERMIT N0.
LEGALt STATE ENCROACHMENT Lam^
DESCRIPTION LOT NO. �- PERMIT NO. -------
BLOCK TRACT r INDUSTRIAL
SIZE OF LOT NWASTE APPROVAL
OW OS
N LOT
CHARGES
USEOF
BUILDINGS Q a9/ / �(.} � l�Q` CONNECTI HARGE FEE
NO. DESCRIPTION OF WORK FEE _ REIMBURSEMENT FE I
HOUSE SEWER CONNECTING TO
PUBLICSEWER . @ 3 3.50 RECEIPT NO. TE BY
HOUSE SEWER CONNECTING TO
P RIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR XCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO' 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 FTYPE
DEPTH
SPECIAL
SPECIAL CONDITIONS ONLY 2.00 M PPEFERENCEONTTOI LENGTH FROM qO/
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT $ 1 1 00 V
AUTHORIZATION TOTAL FEE
IHAVE THIS DATE CONTRACCONTRACTOR TO CONNECT THTE ED ABOVE DESCRIBEDWITH THEI EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER A,/
SIGNED THIS..._IL OF__—_/L/ ..19yA,� NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR /�/j BUILDING OR WORK
OWNERS AGEN .........._._.__.... _:._..... ..C...-----._.._.._......_.._..._
1 SEPTIC TANK,SEEP.PIT(S)
ADDRESS---------------_------_....__.. ....._.._.._.._.._.....�./..._.._.._....__. AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE HAT I HAVE READ THIS APPLI- CESSPOOL DRYWELL
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 I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY: BACKFILL SEPTIC TANKS /I
�� /� A/ SE EP.PIT(S)� CESSPOOLS
SIGNATURE _S--� �Ae .../��
OF PE RMITTErS. -�.. .__.. _;...... . .. ..-.. ..___.................._.....
76A642A 663 7/53 („/�