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Home My Public Portal About6232 BURTON AVE_Sewer__ CBSOB 3 D 62 'I6Afig2APPLICATION FOR PERMIT y 6 2 3 L COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL BUILDING AND SAFETY DIVISIONBm LOING IOHN A. LAMBIE, County Engineer ADDRESS 623 __Bur WILLIAM A. IENSEN, SBP't at Building LOCALITY Ban Gabriel NEAREST FOR APPLICANT TO FILL IN GR055 5T. o don LEGAL / DESCRIPTION LOT NO. 5 OWNER MAIL BLOCK TRACT 5903 ADDRESS NO. OF BLOGY. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE ., DISTRICT NO. GROUP MAP PROCESSED BY BUILDINGS VH BK /PG(X/ CONTRACTOR s F,,i 11 i amQ / !J �^"✓ ADDGCSS 2315 $ 118 St � • CONNECTION DATA CIT`L.A. 59 Calif aEL. N05664608 ST TION /� DEPTH 5. Fye{ STATE / f� PPER REGISTRATION NO. 1�9 9 LJ COUNTY MANHOLE EK NO, DESCRIPTION OF WORK FEETYPEO CONN T LENGTH FROM HOUSE SEWER CONNECTING TO Y. _ P.L. WL.TO P.L d PUBLIC SEW ER $5.00 P.C. O SEPTICTA NK.SEEPAGE PIT OR f . PITS ANO/OR DRgINF1ELD @ $10:00 ND CO.I.I. NO. / !OB NO. V HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ 53.00 CONNECT ADDITIONAL BLDG.OR gFF10AVIT WAIv[R 5[M[x RECORD. INSTIL NO. DATE WORK TO HOUSE SEWER a S3,°O EA OVERFLOW SEEPAGE PIT,GRAINFIELD EXTN.,CESSPOOLORYWELL.MANHOLE@ $5.00 f/) ALTER.REPAIR OR ABANDON HOUSE HWY, OR ST.WIDENING 'z SEWER OR DISPOSAL SYSTEM @ S3.00 STATE ENCROACHMENT PERMIT NO. INDU5TRIAL WASTE APPROVAL CHARGES OWNERS PERMIT s z o0 AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN Nq IED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUSLIC SEWER. APPROVALS GATE INSPECTOR'%SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR ��/�/J � _ �f NEW HOUSE SEWER OWNERS AS ENT_JC...f�r� .� I CONNECT ADDITIONAL BUILDING ORRWORK WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANG/OR GRAINFIELD AND STATE THAT THE ABOVE 15 CORRECT AND AGREECOMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS, CESSPOOL ❑ °RYW ELL ❑ HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/°R ALTER, REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALI FOR NIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROP�TY. ABANDON HOUSE SEWER SIGNATURE OF PERMITTEE / �F BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD CK. M,Q SUPERVISING MECHANICAL ENGINEER { CgSH LhLO 5 3 1 8 w (-,�1 2 8 1 0 A 7,00- ti CEBOB3-62 APPLICATION FOR PERMIT Tsasa2D COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION SU ILOING T+, p JOHN A. LAMBIE, County Engineer ADDRESS 3urton—St WILLIAM A. JENSEN, SuP t of Building LOCALITY San Gabriel NEAREST FOR APPLICANT TO FILL IN CROSS ST, o 59don LEGAL DESCRIPTION LOT NO. (S;03 OWNER MAIL BLOCK TRACT ADDRESB NO. OF BLOGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY �} _ BK PG CONTRACTOR H. Williams I-15 ADDRESS 2315 E. 118 St. - CONNECTION DATA DITYL�f Calif TEL. ND.5664608 Fy'ISTATE ATION DEPTH REGISTRATION NO. 139099 LJ COUNTY � VERPP MANHOLE REF _ NO. DESCRIPTION OF WORK FEE TYPE OFCOLENGTH FROM HOUSE SEWER CONNECTING TO Y. CNN CT R,L. M.L.TO P.L. O PUBLIC SEWER 55.00 SEPTIC TANK.SEEPAGE PIT OR V PITS AND/OR GRAINFIELD C s'oOo CO. IMP.NO. JOB NO. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM I� $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. O CONNECT ADDITIONAL BLDG,OR AFFIDAVIT wE1V[P VS[ME RECORD,INSTR,NO, DATE WORK TO HOUSE SEWER 0 $3.00 OVERFLOW SEEPAGE PIT.GRAINFIELD y E%TN..CESSPOOL.DRYWELL.MANH E® $5.00 ALTER,REPAIR OR ABANDON HO HWY,OR ST.WIDENING Z SEWER OR.ISP SAL SYS M o 53.00 STATE ENCROACHMENT — Y PERMIT NO. WASTEAPPROVALa OWNER'S PERMIT s -r166 CONNECTION CHARGE FEE CHARGES AUTHORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR T0C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLISEWER. APPROVALS DATE INSPE TOWS SIGNATURE SIGNED THIS DAY OF 19_ Q /J OWNER OR �f�5 NEW HOUSE SEWER OWNERS AGENT_ ./ /' / CONNECT ADDITIONAL ADDRESS BVILDING OR WORK SEPTIC TANK.SEEP.PITIS) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANp/OR BEA,NFIELD ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANp/OR ALTER.REPAIR.SEWER OR LICENSED AS REQUIRE. 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, THEABO E E5CRIBED RESI.ENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE OF PERMITTEEBACKFILL SEPTIC TANKS ElSEEP.PITIS) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK. M.0. CASH LnL05 3 1 c'" FM 2 8 1 1 A 2 5.0 Q" WORKERS' COMPENSATION DECLARATION - I hereby affirm that I have a certificate of consent to self 20 W51 DPW 6169 insure, Or a certificate of Workers' Compensation Insurance, or 76A642D Policyl No cop thereof ;ec. n800, Lab C. L APPLICATION FOR PERMIT L1Certifiedcopy is hereby furnished. .. •'^r SEWER - SEWAGE DISPOSAL . ❑ Certified copy is filed with the Ir1`gg 'n pe 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY deijpartment_ / y� I"�' �/�'v� Date 'xFj"9yApplimm \ �i!/!bi— L• / C FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS !P 3p� .zr� STATION DEPTH (This section need not be completed If the work involved by the LOCALIT .MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) NEAREST .� _ LOWER NEAREST TY°E OF CONNECTION M t LENGTH FROM I certify that in the performance of the work for which this csoss ST, r ' 'Cu4e PL .r ML TIDAL permit is issued, I shall not employ any person in any manner LEGAL - P c NO 50 OS t0 become SabeC1 t0 the Workers' Compensation Laws. DESCRIPTION LOT NO, CO LMP 110 TOB NO Date Apphcant BLOCK TRACT TRUNK PERMIT NO .ROAD PERMIT NO NOTICE TO APPLICANT: If, after makingthis Certificate of ASSESSOR A11ID4VIT WAIVER EASEMENT RECORD INSTR NO DATE MAPBOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO.OF SLOGS. Compensationprovisions of the Labor code, you must forthwith SIZE OF LOT - NOW ON LOT ENY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERM"NO I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL Hess and Professions Code, and my license is in full force and ADDRESS CHARGES effect. CITUs� CONNECTION CHARGE FEE.�7�1.5 TEL NO. License Number Lic.Class rl � C'3� iy � �) y-`J M CONTRACTOR ^, �>G� Jff�/r' - REIMBURSEMENT FEE Contractor C.yGl/U, ^�'E4a /�," ADDRESS /�i��g �.L/Z—/J-kr `f�f' DISr41CT NO G40UP BK MAP PROCESSED BY ❑ am exempt under SEG ec. of the L.A.Co. l X70 NO CITY O Plumbing Cade and/or Sec. of the STATE � cLla L '6, � HNA1 U DATE )n Q VALIDATION Z B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL E- Date PUBLIC SEWER BY 1� W SEPTIC TANK SEEPAGE PIT OR Signature PITS AND OR DRAINFIELD W g HOUSE SEWER CONNECTING TO ACCT 8 Z OWNER-BUILDER DECLARATION D .a PRIVATE DISPOSAL SYSTEM hereby affirm that I oat exempt from the Contractor's License CONNECT HOUSEADDITIONAL BLDG OR 3303 c7 20 Law for the following reason (Becton 7031.5, Buisness and Pro- WORK OVERFLOW HOUSE SEWER fessions Code): 'xTN SEEPAGE PIT DRAINDELD 1 ITEMS EXiN.CE POOL DRYWELL MANHOLE ❑ I, as owner of the property, or my employees with wages as 7.AEW EVAIe,oR ABArvooN HOUSE Q TUAL ate' SE WE ISPOSAL SYSTEM 20 their sole compensation, will do the work and the structure is not intended or offered for saleSection 7044, Business C� and Professions Code). sole ( C•HFCK f` ;)�.?(� Ll1,as owner of the property, am exclusively contracting with CHANGE .00 licensed contractors to Construct the project (Section 7044, OWNER'S Permit $ n Business and Professions Code). - AUTHORIZATION TOTAL FEE U CONSTRUCTION LENDING AGENCY I HAVE At THIS DATE A CONTRACT WITH THE HEREIN NAMfD coN R4CtoR ro 0(000-0001 2/15/96 96 .1HE 1 hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED EXI5TING DWELLING TOPUBLIC SEWER D V]pC �� for the performance of the work for which this permit is Y issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ OWNER OR Leader's Name OWNERS AGENT Lender's Address ADDRESS I certify that I hove read this opplicotion 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 representatives of this County to enter upon the ove-meIn' tioned or perty for inspection purposes Signature Permit� Date SEE REVERSE FOR EXPLANATORY LANGUAGE