HomeMy Public PortalAbout5821 CAMELLIA AVE_Sewer__ APPLICATION FOR PERMIT 1
•; .des n-eD
DMSION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
ofd Ea .W
Cotmtr Cf BUILDING
:41 7V
JOHN A. AMBIE, CouN•YY ENtlINEER ADDRESS
L•
ICA88ATT D. GRIFFIN, SUPT OF]BUILDING LOCALITY
EST
FOR APPLICANT TO FILL �N. CR SS SST.
LEGAL - OWNER
D CRIPTIOX LOT 0.
BLOCK TRACT ADD,
..NO. OF BLDGS.
SIZE OF LOT AOW ON LOT CITY L. N0.
USE DV NG8 DISTRICT. GROUP YAP
I BUILD
CONTRACTOR,
ADDRE�¢S - CONNECTION DATA
STATION DEPTH
CITY
TEL N0. 'MANHOLE REFERENCE .
STATE LOWER
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OrWOPLK Fa
HOUSE SEWER CONNro TYPE OF CONNECTIO LENGTIi FROM
PUBLIC SEWER' g 3.50 Y. CURB Y.L.T P.L.
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 3.00
VERFLOW SIE9PAVE PIT, DhAlkPIELD CO. I P X0. - JOB N0�
EXT M.,C POOL,DRYWELL MANHOLE 2.00
HOUSE SEWER CO!(NE ]"G TO -
PRIVATE DISPOSA SYSTEr- Q s 1.00 TRUNK PER IT f10. ROAD P IT NO.
CONNf CTADDITIOXAL BLDG.OR STARE ENCROACHMENT
WORK TO HOUSES ER Q S 1.00 PERMIT NO.
ALTER,RKPAJR OR A13AND014 HOUSE INDUSTRIAL
SERER OR DISPOSAL SYSTEM 8 1.00 WASTE APPROVAL
CHARGES
CON-NECTION CHARGE FEE -
OWNER'S PKBbtT i 1 00 IYSUR-SEM EMI`FEE
AT7THOR=AiY alOTOTAL FES RE .
I HAVE AT THIS DATE A CONI ACT WITH THE HEREIN RAYED CON- APPROVALS DATE JNSPE OR'SSIQNAT E
nACTOR TO CONNECT THE ABOVE DESCRIBED F,KI$TING DWELLING
TO THE PUBLIC 9 NER HOUSE SEWER
SIGNED THH AY OF +Z� CONNECT APDITIONAL
OWNER OR BUILbimG OR WORK '
OWNERf AGENT SEPTIC TANK,SEEP,PIT(S)
ADDREB /OR DRAIXFIELD
I HEREBY ACKNOWLEDGE THAf I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND "REE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPO AL SYSTEM
1 HEREBY CERTIFY THAT 1 AN PROPERLY R ISTERED AND/OR DISCONNECT PLUG AMD
LI-CEN91<D AS REQUIRED BY LOS ANGELES C A�1D STA OF ABANDON HOUSE SEWER
CAI,I�'ORNI OR THAT y THE L L XER OF THH SOME
DESCRIBED BEEIDENTI ROPERrY. BACKFILL SEPTIC TAxk-%
61GNoURC
SEEP.PIT{S) [ICESNPOOLS❑
_
OF PERYI
JOHN A LAIv4B1$ N61NEEft ALMATIO ROBF—RT A.W OD, Cr 110 PuaG. INOPECTOR
x 2 0 11--
11113 4 4.50
0 '..WORUJtR '.comPENSATJON DECLARATICIN
I hereby Safflr>n that I hover'Q certificate of consent to self 76A642 Dew ai®
Insure, or d certtfl of Workers'Com nation Inwronce, or 7E
f� � APPLICATION FOR PERMIT
all Ro. Com. � �s
E,��rlfle!dcopyy :hereby fuml.hed. SEINER - SEWAGE DISPOSAL
C.1ifled copy Is f1196 with the punty building I Ion COUNTY OF LOS ANGELES BUILDING AND SAFETY
�
Da tII FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF DQ JMON FROM WCiRICERs 61,
SDI NG
COMPENSATION INSURANCE ADDRPSS T" DEFTH
(fhls section need not be completed If the work Involved by the LocALnY MAN-IOtF TIPPER
permit Is for one bundhsd dollars (;100)or less-) TYPE'OFCONNECTON LENcTHiFROM
LLOWEEP
I certify that In the performance of the work for which this CIi06S%T. !� �C Y. CURB PL AL TOP.L
permit Is Issyed, I shall not-empploy any person in gny.manner
so as,to become subject to the Workers'Compeniatloll Laws. CO. .tp y��p:
owNER C
PERW NO. ROAD PERMIT No.
Date Appllcant L�
NOTICE TO APPLICANT: If, after making this Certificate of CTY TEL AFRDAvrI I WAVER EAmma4T ;Eww.wSrR No. DATE
Exemption, you should become subject to the Workers' LWAL
Compensation provisions of the Labor code,.you must forthwith DESCRIPTION uDT NO. HWY OR ST WID04ING
compty with-such provisions or this permit shall be deemed
reyoked. eioac TRACT SrATedAc?vnelr
LICENSED CONTRACTORS DECLARATION NO.OF BLDG& PEW uT ra.
I hereby gfflrm that I am licensedSRF OE LOT Now ON LOT
under provlsldns of Chapter �
9 (Comalentlno wltb Section 7000) of DIVISJOn 3 of the Dual- 5u CHARGES
nese and Professions Code,-and my license Is In full force and
effect. /- CONTRAGYOR ODNNEq ON C FLEE
4:4
NX Z-7 `� Llc.Class �/ • �� ADDS r$
a
O
�� .r DMTRICT NO, GROUP AM,P ()
TE BK PG Z
❑ 1 am exempt u Sec. of the LA.Co. UC9t3E No. –' r 3 — Zi7 O
t-
U
Plumbing Code and/or Sec. of the No. '$HOUSE-SEWER CCONNECTNG TO VALIDATION W
WER
B. & P. Code for the following reason PUBLIC A.Nk &EEPAGE PIT OR R ✓� �� Z
Date PATS DRAJNHELD DY
signature- CONriCT ADDrnONAL BLDG.OR
OWNER BUILDER DECLARATION
WORK TO HOUSE SEWER
NFIEW
I hereby affirm that I am exempt from the Conlroctor's License acrx C SWAGE� �mAu bu
Law for the following reospn (Secton 7031.5, Bultness and Pro- K OR ABANDONSYSTEM
Cod*):
OR DMPO&kL El I,at pwner of the property,or my employees with wages as
their sole compensgtlon, will do the work and the structure
Is not Intended or offered for sale (Sectlon 7044, QUslRess
and Professlons Code). - OWNER'S Permit' 3 16
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE °
licensed coAtracrors to construct the project (Sectlon 7044, I HAVE AT THIS DATE A CDKTRACT WITH THE HEREIN NAM® OR TO
Bwln}ss and Professions Code). CONNECT THE ABOVE DESc�EX_MnNha DWELW TO THE PIJaUc SEWHt
CONSTRUCTION LENDING AGENCY ° � �2;1 5{J�
F I hereby affirm that there Is a construction lending agency �® �— —DA'YOF 19_ , 1,
� 09. 1 :3'=88
for the performance of the, work for which this permit Is Iwii
Issued (Sec. 3097, Civ. C.).
ADDIS ,
Lender's Name mom
Lendeds Address -
I certify that I havq read this oppllcotlorl and.state that the
above Information Is correct. 1 agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and herby authorize representatives- of this County to enter
upon the above.-mentlo ape fordo+purposes.
Signature of mlttee Date $0 RltVRU FOR LXPLANATORY LAPO UA04