HomeMy Public PortalAbout4858 CLOVERLY AVE_Sewer__ DEPA-RTNMNT OF COUNTY ENGAV"EER i SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL N LOCALITY � J
BUILDINGNEAREST
ADDRESS '� Qom► CROSSST
LOCALITY DISTRICT NO SERIAL NO U PERMIT NO
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NEAREST D
CROSS ST �{ _ eit.dl,�s ---
RECjE�I/V�E0 BY Ready for Inspection DATE ISSUED �/
OWNER -� ' - ' T
MAILt'G' /J /J ¢� USE ZONE OCCUPANCY MAP
ADaRCSS rGJJ t7 PT/! 'JJ _ BK PG
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CITY / � TEL NO. Aor` y'�0 b/ - I /LT'U
CONTRACTOR 0?', go, >..t�d�� � � G°® CO.IMP NO.
ADDRESS - /� �, Z,_AA,� /J _ JOB NO
CITY TEL NO � � �,�� TRUNK PERMIT NO
STATE
REGISTRATION NO ,e1 ,3C I,/a �sp_ VA R-COLEXTY ROAD PERMIT NO
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO PERMIT NO
BLOCK TRACT //'yl�y�� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NOW)F BLDGS CHARGES
NOON LOT
USE
BUILDINGS CONNECTION CHARGE FEE
,�.� _
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
1 HOUSE SEWER CONNECTING TO e�
PUBLIC SEWER 0 $ 350J 'S� RECEIPT NO I DATEi I BY
HOUSE SEWER CONNECTING TO /
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION REjCOROED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO ATE BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR /
PITS AND/OR DRAINFIELD 200 STATION f'(/p �� S DEPTH
CESSPOOL—DRYWELL / MANHOLE REFERENCE
SPECIAL CONDITIONS ONLY 200
Y��i� l URPER- i LOWER
TYPE OF CONN Jf TT10N LENGTH FROM
�v CURB M L TO P L Ll
OWNERSPERMIT ; I 00
AUTHORIZATION TOTAL FEE �n
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS 26--D Y OF __ -_ 13 NEW HOUSE SEWER � lln� 3 ' -4CONECT
OWNER OWNERS OR NT t ` - - - BUILDING OR WORK
ADDITIONAL
SEPTIC TANK SEEP.Py
ADDRESS ? Z_-®� AND/OR DRAINFIELD IT(S) y
I HEREBY ACKNOWLEDGE THAT I HAVE READ HIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE ] ,y SEEP PIT(S)E] CESSPOOLS p G -
OF PERMITTEEe'
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