HomeMy Public PortalAbout4815 CLOVERLY AVE_Sewer__ D
6&E 669 11 S9
APPLICATION FOR PERMIT
8&E 6
DIVISION OF BUILDING AND SAFETY SEWER-SEWA E DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO LL INS I CROSS ST
LEGAL OWNER
DESCRIPTION LOT NO
i MAIL
BLOCK TRACT ADDRESS
NO F BLDGS CITY NO
SIZE OF LOT NO ON LOT
USE OF DISTRICT NOr_GROUP MAP
BUILDINGS
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS
TATION DEPTH i
CITY TEL NO
MANHOLE REFERENCE
ATE LOWER
REGISTRATION N COUNTY
NO DESCRI I(n OF WORK FEE
TYPE OF CO TION LENGTH FROM f
HOUSE SEWER CONNECTING TO y �B p L M L TO P L
PUBLIC SEWER @ $3 50
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD `�/��I P C NO
EXTN CESSPOOL DRYWELL MANHOLE,@ $2 00 CO IMP NO 41 E9 JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO CL `
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $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 S 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE .) Q
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON APPROVALS DATE INSP CTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER I '�
SIGNED THI D Y 1 y CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK `
OWNERS AGEN SEPTIC TANK,SEEP,PIT(S)
'
ADDRESS% b 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 REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I EE'GAL 0 N OF ABOVE
TANKS
DESCRIBED RES IDENT]A PERSEEP BACKFPIT(SEPTIC❑ CESSP00❑LS �.�
ILL
SIGNATURE c
OF PERMITTEE —
JOHN AIL/AMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK M 0 ASH
j AC04 6 0 31J-) JAN30 4 4,5 0
I{
WORKERS COMPENSATION DECLARATION
1-hereby offlrry that I have a certificate of consent to self
ii)sur-e, or a certificate of Workers"'Compensation Insurance, or 76A642D
acertifiedicopythereof jSec 3800 LabC ) CE808(REV 8/8)) APPLICATION FOR PERMIT
.Policy No _Company OS
❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS �yeALl A-ve STATION DEPTH
(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 jC�A')P�-� G[ T� LOWER
NEARESTTYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this CROSS ST 1--0 Vilew� l�V+It Y CURB P L MIL TOPI.
permit Is Issued I shall not empl ny person`in any manner
/n � / / P C NO
SO OS 10 become subject to the Or r5 C pens f LOWS OWNER (y U �✓r CC?'� CO IMP NO P C NO
l/ MAIL +1 C � �Ly y.�+ TRUNK PERMIT NO ROAD PERMIT NO
Date tl j Applicant ADDRESS
NOTICE TO APPLICANT If, after makingthis Certifl to Of (7%/
! AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
CITU � C I�� TEL NO
Exemption, you should become subject to the orkers LEGAL q
Compensation provisions of the Labor code you must forthwith DESCRIPTION LOT NO K HWY ORST WIDENING
comply with such provisions or this permit shall be deemed /
revoked BLOCK TRACT // STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATIONNO OF BLDGS PERMIT NO
SIZE OF LOT J00 k '7S NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter GSE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code and my license Is in full force and t
effect CONTRACTOR shoo ig CONNECTION CHARGE FEE
License Number LIC Class ADDRESS REIMBURSEMENT FEE O
Contractor Date DISTRICT NO GROUP MAP ESSED BY V
CITY TEL NO BK PG Z
STATE LIC /� t 1„/ L Q
El am exempt under Sec of the L A Co LICENSE NO LICCLASS
V
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL VALIDATION LU
HOUSE SEWER CONNECTING TO DATE
N
8 8 P Code for the following reason PUBLIC SEWERSEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM C�a
Signature CONNECT ADDITIONAL GhB9-6fr 1/
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT DRAINFIELDEXTN 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) OWNER'S Permit $ /,
❑ 1, as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE /
licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ;25964A
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
CONSTRUCTION LENDING AGENCY # 0 0 0 0 O
I hereby affirm that there Is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit Is OWNER OR 111 , 921. 50
Issued (Sec 3097, Civ C ) OWNERS AGENT o 0 0 2 1.5,0 6
ADDRESS
Lender s Name
Lender s Address
j,1 1, 1 8t-86
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 jaws regulating Plumbing and Sewers,
on eby authorize r presentatives of this County to enter
u on th above- enti ed operty for Inspection purposes
t
Signature of Permi a Date SEE REVERSE FOR EXPLANATORY LANGUAGE