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Home My Public Portal About6222 BURTON AVE_Sewer__ CE30B 3-E4 p APPLICATION FOR PERMIT - EEBOB COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING e JOHN A. LAMBIE, County Engineer ADDfl Ess .(, WILLIAM A. JENSEN. Supt of Building LOCALITY NEAREST 44 FOR APPLICANT TO FILL IN CROSS 6T _ LEGAL DEBCRIPTI ON LOT NO. A ['J OWNER-t' p MAIL BLOCK TRACT y ADDRESS SLOGS. 612E OF LOT NOW ON LOT CITY TEL. NO, 1 USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY BK PG CONTRACTOR '$2, ADDRESS - CONNECTION DATA CITY R TEL. NO O STATION ` DEPTH ESTATE Ygl"GTP REGISTRATION NO. ❑ COUNTY MANHOLE FERENCE ^!• OW NO, CESCRP ON OF WORK FEE TYPE OF CONNECTIO 'V LENGTH FROM ROUSE SEWER CONNECTING TO Y. CURB P,L, M.L.TO P.L. PUBLIC SEWER G $5.00 SEPTIC TANK,SEEPAGE PIT OR P.C.NO. CL CL PITS AND/OR DRAINFIELD ® $10.00 CO.IMP. NO. JOB NO. O 0 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER E111IMtxT RECORD.INBTq. NO. DATE O WORK TO HOUSE SEWER ® $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD v E %TN..CESSPOOL,DRYWELL.M AN H OLE* $5,00 ALTER,REPAIR OR ARAN 0 O HOUSE HWY.OR ST.WIDENING U-1 SEWER OR DISPOSAL SYSTEM ® $3.00 h UREIMBURSEMENT T ENCROACHMENT T NO. _Z TRIAL APPROVAL CHARGER OWNER'S PERMIT S z 00 AUTHORIZATION TOTAL FEE CTION CHARGE PEE 'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. a• n APPROVALS DATE INSPECTORS SIGNATURE SIGNED THIS E DAY OF 19rAJ OWNER OR ,( NEW HOUSE SEWER -y .gJVx-!W'✓ OWNERS AGENT F� A� L'A �f 1 ^_ �•A✓�1e1 Y/ /CONNEC BT ADDITIONAL ADDRESS 'V I /-- / - H`ll'•"f" �Z I �I C- �%C'F U ILpING OR WORK I HEREBY ACKNOWLEDGE THAT 1 NAVE READ THIS APPLICATION SEPTIC TANKSEEP,PIY(S) AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CDMPLY AND/OR GRAINFIELD WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND ALTER.REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED RESIDE PR Y. ABANDON HOUSE SEWER _ f SIGNATURE OF PERMITTEE /E1� BACKFILL 9lITI �S VALIDAT ROBERT A. WOOD CK. m.o. cgsH SUPERVISING MECHANICAL ENGINEER L& 4 7 4 8�2 1.020 1 0 n 7.00 N WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or o certificale of Workers'Compensation Insurance, or 76A642D I' a certified copy thereof (Sec. 3800, Lab C.) �- //// �E808(REV.I18]) APPLICATION FOR PERMIT u Policy No '"'�-�" SEWER - SEWAGE DISPOSAL ❑ Certified copy is hereby furnished. t Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date//J7--lillSAppucant a FOR APPLICANT TO FILL IN CONNECTION DATA c CERTIFICATE OF EXEMPTION FROM WORKERS' BmmING U�n STATION COMPENSATION INSURANCE ADORE55 (This section need not be completed if the work involved by theUPPER LOCALfrY -1 j,r MnNHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this NEARESSt. TYPE OF CONNECTION LENGTH FROM CROSS permit is issued, I shall not employ any person in any manner OA 7. Y. CURB PL. M.L.TO P.L. � P C No so as to become subject to the Workers' Compensation Laws. OWNER �/I/ CO.IMP NO, JOB NO. Dale Applicant ADD MAILRESS Q TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making cae oCITY this Certificate TEL.No AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE �/ 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 BIOGs. PERMIT No. SIZE CI NOW ON LOT / 1 hereby affirm that 1 am licensed under provisions of Chapter u5E of 9 (commencing with Section 7000) of Division 3 of the Busi- BURDINGS I�aG CHARGES ness and Professions Code, and my license is in full force and effect. ///(//� CONTRACTOR �-.l�V CONNECTION CHARGE FEE License Number / /�IC.Class -v�J'7 ADDRESS �/JfC/ (� REIMBURSEMENT FEE Contractor Date // �P 0 DISTRICT NO. GROUP MAP PROCESSED BY O CITY iEl.NO. /^ /E � BK PG 19 STATE CL J (� ❑ I am exempt under Sec..of the L.A.Co. LICENSE No. QA55 O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL 'HOUSE SEWER CONNECTING TO /1 DATE VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER (/ SEPTIC TANK.SEEPAGE PIT OR N Date PITS AND/OR DRAINFIELD FI Z _ HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature— CONNECT ADDITIONAL SLOG.OR Pilo DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractors License ExTN.,CESSPOOL DRYWELL MANHOLE 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 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 8 2 3 5 3 7 A ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 3-i) licensed contractors to construct the project Section 7044, # o e e o 0 P ( HAVE T THIS DATE E CONTRACT WITH THE HEREIN NAMED CONTRACTOR t0 Business and PFOfeSsiOns Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING i0 THE PUBLIC SEWER. ( O - 27450 CONSTRUCTION LENDING AGENCY �/ SIGNED THIS // U 19_ hereby affirm that there is a construction lending agency , o e e s for the performance of the work for which this permit is OWNER AGENT /�JCfY 2 7.5 o OWNERS AGENT issued (Sec. 3097, Civ. C. .� gppafss '� �/.�Cr_ C 01�2 2._8 5 Lender's Name 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 re se Qtives of this County to enter upon the above-menti operty for inspection purposes. ig�Signature rm at �iL�s SEE REVERSE FOR EXPLANATORY LANGUAGE