HomeMy Public PortalAbout5426 CLOVERLY AVE_Sewer__ CE8082/70 PERMIT FOR SEWER
76A 6421)
COUNTY OF LOS ANGELES SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FLO.-A
ILDING
JOHN A. LAMBIE. COUNTY ENGINEER RESS
COLEMAN W. JENKINS. SUPT. OF BUILDING
LITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
(PRINT OR TYPE ONLY) ---_—_- _ —
LEGAL _
[BUILDINGS
SCRIPTION LOT NO. OWNER
MAIL
OCK TRACT ADDRESS
NO. OF BLOGS.
ZE OF LOT NOW ON LOT — CITY TEL, NO.
E OF DISTRICT NO. GROUP CLASS ^AAP PROCESSED B�
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CONTRACTOR -
�I1 ADDRESSCONNECTION DATA
I- CITY TEL. NO. O STATION DEPTH
STATE LIC UPPERMANHOLE REFERENCE
LICENSE NO. CLASS LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ slo.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. EL
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD. INSTR. NO. DATE V
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD nJ
J
EXTN..CESSPOOL.DRYWELL.MANHOLE @ 45.00 HWY.OR ST.WIDENI n.
ALTER.REPAIR OR ABANDON HOUSE ,�,
SEWER OR DISPOSAL SYSTEM @ $3,00 STATE ENCROACHMENT
PERMIT NO. Q
INDUSTRIAL d!
WASTE APPROVAL O
OWNERS PERMIT S 2 OO CHARGES
CONNECTION CHARGE FEE uJ
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT-FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING READ CONDITIONS BELOW
TO THE PUBLIC SEWER.
SIGNED THIS DAY of 19
OWNER OR THIS FORM WHEN PROPERLY MACHINE VALI-
OWNERS AGENT DATED BELOW IS A PERMIT TO DO THE WORK
ADDRESS DESCRIBED.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION Permittee is hereby authorized to install the work
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY as shown, in accordance With provisions of Ordin-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. once No. 2269 and related Ordinances.
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR This permit becomes null and void if work is not Com-
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF menced. within 60 days from date of issuance,
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO OI if WOIk 1S SUS ended at an time during con-
SIGNATURE
IN. THE ABOVE DESCRIBED. RES
IDENTIAL PROPERTY. p y g
SIGNATURE struction for a period of 120 days, or if any Work is
OF PERMTTTEE ,_--______ __ done On the said building Or structure In Violation of
the Covinty Ordinances or State laws governing same.
VALIDATION a JACK R. ALLEN
CK. M.O. CASH yUPERVISING MECHANICAL ENGINEER