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HomeMy Public PortalAbout5521 CLOVERLY AVE_Sewer__ I 76A6r3194 E 86 iAPPLICATION FOR PERMIT 1 - Q .DIVISION OF BUELDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles BUILDING WM J FOX, COUNTY ENGINEER ADDRESS ` e CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY e f.e L FOR APPLICANT TO FILL IN NEAREST �r a CROSS ST D SE RIPTION LOT NO I S/ OWNER f, y�,e S �� $ BLOCK TRACT '� .r MAIL r ADDRESS NO OF BLDGS /J •NO SIZE OF LOT S y NOW ON LOT CITY -moi USE OF BUILDINGS Sc O O DISTRICT NO GRO P MAP BK PG CONTRACTOR ` / 30 ADDRESS " 3 S` OVA- ��t 6— CONNECTION DATA CITY (f4r&_S1, C,4 •e 6i1:C1 TEL NO �y 34 ! STATION DEPTH ' ❑ STATE MANHOLE REFERENCE REGISTRATION NO � ❑ COUNTY - UPPER LOWER TYPE OF CONNECTION LENGTH FROM NO DESCRIPTION OF WORK FEE Y CURB PL L TO P L HOUSE SEWER CONNECTING TO 0' B IS ®& _ PUBLIC SEWER Q $ 3 50 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 100 rCONNECT ADDITIONAL BLDG OR �® CO IMP NO JOB NO WORK TO HOUSE SEWER 1 00 ALTER OR REPAIR EXISTING _ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO SEPTIC TANK, SEEPAGE PIT OR --PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 CHARGES CONNECTION CHARGE FEE OSS PERMIT S 1 00 AUTHORIZATION TOTAL FEE 2_ DO REIMBURSEMENT FEE TRACTOR TTOSCONNECT THEDATE AABOVE DESCRIBED EXISTINGCTED WITH THE HEREIN ADWELLING APPROVALS _ D4TE INSPECTOR 5 SIGNATURE TO THE PUBLIC SEWER NEW HOUSE SEWER SIGNED THIS DAY OF 19- OWNER OR CONNECT ADDITIONAL l� �5 OWNERS AGENT BUILDING OR WORK SEPTIC TANK SEEP, PIT(S) v ADDRESS - AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND„STATE OF ABANDON HOUSE SEWER CALIFORNIA THAT 1 AM THE L OWNER OF HE ABOVE DESCRIBED RESISI DENTIAL PROPE BACKFILL SEPTIC TANKS [ISEEP PIT(S) [ICESSPOOLS❑ SIGNATURE w OF PERMITTEE WILLIAM J FOX,COUNTY ENGINEER VALIDATION &8686 OCT 5, 4 200 BY BY DEPUTY DEPUTY BY BY © DEPUTY DEPUTY r S&E 669 12 54 APPLICATION FOR PERMIT DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Department of County Engineer ' County of Los Angeles BUILDING ADDRESS ss' 7/ C / , 'm / WM J FOX, COUNTY ENGINEER /E•✓ Y Y CASSATT D GRIFFIN SUP T of BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST �0/� !� CROSS ST i LEGAL ! ...� DESCRIPTION LOT NO .j OWNER 6, BLOCK TRACT � z / ) MAIL � ate== ADDRESS LDG SIZE OF LOT 14 A �`f�%'40WO0NBLOTS CITY TEL NO USE OF BUILDINGS r ' DISTRICT�O GROUP MAP PG CONTRACTOR !'�( Z14/r VA �/ ADDRESS CONNECTION DATA CIT TEL NO STATION DEPTH ❑ STATE MANHOLE REFERENCE REGISTRATION NO ry �j UPPER LOWER / TYPE OF CONNECTION LENGTH FROM NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L f HOUSE SEWER CONNECTING TO -� ��.yV _ PUBLIC SEWER Q $ 3 50 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO WORK TO HOUSE SEWER 1 00 670 ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM ION TRUNK PERMIT NO ROAD PERMIT NO DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO SEPTIC TANK SEEPAGE PIT OR _ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 CHARGES s o0 OWNER'S PERMIT CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE /O REIMBURSEMENT FEE TRACTORHAVE TTO CONNECT THEHiS DATE A ABOVEWDESCRIBEDEXISTINGITH THE HEREIN A DWELLING CON APPROVALS DPTE INSPECTOR S SIGNATURE TO THE PUBLIC SEWER p! C e Q NEW HOUSE SEWER Q ' !, � SIGNED THIS DAY OF _19- OWNER l9 OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK, SEEP, PIT(S) ADDRESS I AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONL ❑ DRYWELL❑ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGE PAIR,SEWER OR PLUMBING AND SEWERS SPOSAL SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/ORCT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFHOUSE SEWER CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY SEPTIC TANKS❑'v S) ❑ CESSPOOLS❑ SIGNATUREIi" � OF PERMI E 1 WILLIAM J FOX, COUNTY ENGINEER VALIDATION __AC0 8 3 5 4 SEP 2 6 4 600 tn 'BY BY DEPUTY DEPUTY BY BY R_ 7 ® DEPUTY DEPUTY .WORKERS COMPENSATION DECLARATION 20 0051 DPW 6/89 U 1 hereby affirm that I have a certificate of consent to self Insure or a certificate of Workers Compensation Insurance or / �6Asa2D r a certified copy thereof (Sec 3800 APPLICATION FOR PERMIT Policy No Company I<Certifted copy is hereby furnished SEWER ,- SEWAGE DISPOSAL Certified copy Is filed wit unty bulldin trio COUNTY OF LOS ANGELES BUILDING AND SAFETY de rt t �� Date�Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTIO ROM WORKERS BUILDING r COMPENSATION INSURANCE ADDRESS r TATION DEPTH (This section need not be completed if the work Involved by the M 06? '� MANHOLE REFERENCE /n UPPER permit is for one hundred dollars ($100) or less ) LOCALITY C [�� LOWER NEARESTO l TYPE OF CONNECTION f LENGTH FROM I certify that In the performance of the work for which this CROSS ST �' (� v CURB P L M L TO P L permit is Issued I shall not employ any person in any manner LEGAL so as to become subject to the Workers Compensation Laws DESCRIPTION LOT No P C NO P CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant NOTICE TO APPLICANT If after making this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAP BOOK PAGE PARCEL Exemption you should become subject to the Workers NO OF BLDGS Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF evoked BUILDINGS STATE ENCROACHMENT �� LICENSED CONTRACTORS DECLARATION 61 PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER 1 9 (commencing with Section 7000) of Division 3 of the Bust MAILq 4 CHARGES ness and Professions Code and my' license is In full force and ADDRESS � J� C ` effect CITY Ze E O 8� �9Y71 1 CONNECTION CHARGE FEE License Num er + c Class jjl� REIMBURSEMENT FEE ContractorV11 Uat@ CONTRACTOR DISTRICT NO GROUP MAP PROCESSED BY ADDRESS �— BK PG ❑ I am exempt under Sec of the L A Co ,�_ D� �f� /.!� �L4�—G } CITU EL N V a O PlumbingCode and/or Sec of rhe STATE �y LIC FINAL V LICENSE NO �"-{c CLASS DATE VALIDATION tJ VALIDATION ZO B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE J, _G J HOUSE SEWER CONNECTING TO FINAL f-- Date PUBLIC SEWER BY LU SEPTIC TANK SEEPAGE PIT OR d SlgnOfUl - PITS AND OR DRAINFIELD N HOUSE SEWER CONNECTING TO Z OY ER BUILDER DECLARATION PRIVATE DisPosAL SYSTEM �I� I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OR Law for the following reason Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER fessions Code OVERFLOW SEEPAGE PIT DRAINFI e�!' ) E%TN CESSPOOL DRVWEIL MANHOLE HOLE ❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM their sole compensation will do the work and the structure ��t�yC is not Intended or offered for sole (Section 7044 Business jC and Professions Code) e[_sT1*)L 56 ❑ I as owner of thero err am exclusive) g contractin with licensed contractor to construct the project (Section 7044 OWNE 'S Permit $ t IyY{ ero_C Business and Professions Code) AUTHORIZATION TOTAL FEE 67 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED coNrRAcroR TO I hereby affirm that there Is a construction lending agency CONNECT THE ABOVE DESCRIBED ExISTiNG DWELLING TO THE PUBLIC SEWER for the performance of the work for which this permit is c Issued (Sec 3097 Qv C ) SIGNED THIS DAY OF 19_ OWNER OR -{ _ r Lender s Name OWNERS AGENT ��L+,f t 1 All £arI_ Lender s Address 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 andautho ize representatives of this County to enter n thea ove mentioned ro rty for I c peon purposes 9�~ signalu f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE