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HomeMy Public PortalAbout4812 CLOVERLY AVE_Sewer__ I , D S&E-683 11-55 APPLICATION FOR PERMIT 1 3&E•6 DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles BUILDING Z JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO. -2OWNERMAIL BLOCK TRACT - ADDRESS N0. OF BLDGS. SIZE OF LOT j NOW ON LOT CITY TEL. NO. USE OF DISTRICT NO. GROUP MAP BUILDINGS .L� BK PG ' CONTRACTOR C � ADDRESS CONNECTION DATA a'oT'� �' G�-� STATION DEPTH CITY ...7• TEL. NO. - MANHOLE REFERENCE - UPPER / ❑ STATE LOWER 7"p-"7'q REGISTRATION NO. Y J'q ❑ COUNTY NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF TION LENGTH FROM a2_5 PUBLIC SEWER @ $3.50 CURB d M.L,TO P.L. SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD PC* NO. EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. Z 5 /a 100 N0. HOUSE SEWER CONNECTING TOO / @ PRIVATE DISPOSAL SYSTEM $1.00_ TRUNK PERMIT NO. ROAD PERMIT N0. CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT WORK TO HOUSE SEWER Q $1.00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 5 NEW HOUSE SEWER SIGNED THIS DAY OF /_ / 7 19� ���/ CONNECT ADDITIONAL OWNER OR b A 1_ G"`C-" !j✓V`--�... BUILDING K,WORK OWNERS AGENT Y/ Lt/�/ SEPTIC TANK,SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ } AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF , ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM TH LEGAL OWNER OF THE BOVE DESC t;ED R SIDENTIAL PROPER BACKFILL SEPTIC TANKS SIO A'YE _ �_'^�' �� SEEP. PIT(S) ❑ CESSPOOLS❑. JOHN A. LA"IE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR CK. N. 0. ASH {t'o 2 66, JAN 17 4 4.5 U � /I \77 WORKERS' COMPENSATION DECLARATION Fertlied eby affirm that I have a certificate of consent to self e, or,a'certifcate of W'ork'ers'Compensation Insurance, or 76A642D copy'hereof (Sec. 3800, Lab C.) CE 808(REV.Bl81) APPLICATION FOR PERMIT ?�� `Company ©s Certified copy is hereby furnished. SEWER -'SEWAGE DISPOSAL ❑6Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN 'p /� CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �f �f _1.1{a/ y�f i p.}.pp��i . STATION �1 � ,� DEPTH COMPENSATION INSURANCE ADDRESS •!� Q�/Y�i lL(. i1 '+I-� 19 (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY 0 LOWER NEAREST J R C/p L� Z f,5 4 TYPE OF CO TION w I certifythat in the performance of the work for which This CROSS ST. `�/W+�ICS /J V LENGTH FROM V�/t✓"S f P V. CURB P.L. M.L.TOP.L. permit is issued, I shall not employ any person in any manner ,�,1y 0 ,, so as to become subject to the W rs' C ation Laws. OWNER M A N V F L *— �1"{--E54 CO.IMP.NO, JOB NO. •'",� `� MAIL _ TRUNK PERMIT NO. ROAD PERMIT NO, Date I Applicant ADDRESS .c� NOTICE TO APPLICANT: If, after makin this ertificate of 570/6 / AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g CITY 1 TEL.NO. VVV v Exemption, yof should become -subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOTNO. 1, �v�m® HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. 1k BLOCK TRACT STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO. LICENIJSED CONTRACTORS DECLARATION SIZE OF LOT X 11 6 NOW ON LOT I hereby affirm ihat I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES ness and Pr ofessions Code, and my license is in full force and effect. CONTRACTOR ,T CONNECTION CHARGE FEE h'l •<' _.ensue Number Lic.Class ADDRESS REIMBURSEMENT FEE Contractor Date . DISTRICT NO6 . GROUP MAP PROCESSED BY %)CITY TELNO. BK PG ❑ UC0 1 am exempt under Sec. of the L.A.Co. STATE CL P LICENSE NO. CLASS NO. DESCRIPTION OF WORK FEE Plumbing Code and/Or SEC. O{the ' k-3 L /Ca HOUSE SEWER CONNECTING TO DA L EVALIDATION B. & P. Code for the following reason PUBLIC SEWER I V SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL g Date HOUSE SEWER CONNECTING TO - BY i PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER SEEPAGE IELD {�] I hereby affirm that I am exempt from the Contractor's License EOXTNFLOC CESSPOOL,DRYW LL, MAFNHOLE 10 Law for the following reason (Secton 7031.5, Buisness and Pro- r•p -ALTER,REPAIR OR ABANDON HOUSEg fes Ons Code): SEWER OR DISPOSAL SYSTEM ACCT.T ' as owner of the property,or my employees with wages as 335137 2d 50 ass•. their sole compwnsation, will do the work and the structure t is not intended or offered for sale (Section 7044, Business 1 ITEMS' and Professions Code). OWNER'S Permit $ �i ,, �. AUTHORIZATION JCONTFrACTOR `a ❑ I,as owner of the property, am exclusively contracting with TOTAL FEE CHECK licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CHECK `1'°C�lBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUB ..CONSTRUCTION LENDING AGENCY , CHAN E °(1��I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS 0000-0001 9/12/89 ' Lender's Name 5662 1 AM11:3 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 representatives of this County to enter upon bove-mentioned property for inspection purposes. err, Signature of Permitt a Date SEE REVERSE FOR EXPLANATORY LANGUAGE