HomeMy Public PortalAbout5538 CLOVERLY AVE_Sewer__ 1 6&E 6GG3 12 54 APPLICATION FOR PERMIT ],
Y 8 G E
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
» Deportment of County Engineer
County of Los Angeles BUILDING (r"�
WM J FOX, COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN SUP T of BUILDING LOCALITY
FOR PLICANT TO FML IN NEAREST
CROSS ST
LEGAL / 1 `
DESCRIPTION LOT OWNER
BLOCK - ' ~ , 06 MAIL �Av!
ADDRESS
c - NO OF BLDGS r
SIZE OF LOT '-'--�» NOW ON LOT CITY e NO .3
USE OF
BUILDINGS �� DISTRICT NO GROUPI MAP
BK PG
CONTRACTOR
/_')
ADDRESS CONNECTION DATA
CITY TEL NO STATION STATION D �'� DEPTH
MANHOLE REFERENCE
REGISTRATION NOCOUNTY -1 t7 T4" LOWER
�� [I TYPE OF CONNECTIO! LENGTH FROM
NO DESCRIPTION OF W0' FEE Z CURB .FPS M L TO P L
' HOUSE SEWER CONNECTING TO
_ PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM `1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO Sa �"„[ 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
OWNER'S PERMIT $ t 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE D CRIBED EXISTI G DWELLING APPROVALS DATE INSP CTOR S SIGNATURE
TO THE PUBLIC SEW R
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER �Q
OWNEROR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESJr&jIa&4] AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE R D THIS 'PPL
AT CESSPOOL[I DRYWELL C)AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS R ULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSCEN
1 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 OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS ,,,� �"°"""'
SIGNATURE
OF PERMITTEE
WILLIAM J FOX. COUNTY ENGINEER VALIDATION
BY .ACos a 9 3U- AUG'19 4 4.5 0
BY
„ DEPUTY DEPUTY
'BY BY
I .® DEPUTY dEPUTT
WORKERS' COMPENSATION DECLARATION
20-0051 DPW 6189
1 hereby affirm that I have a certificate of consent to self
76A642D
insure, or a certificate of Workers' Compensation Insurance, or �
a certified copy thereof (Sec. 3800, Lab C. APPLICATION FOR PERMIT
Policy No. Company
Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
El
❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
deportment.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING � �� STATION ` DEPTH /
COMPENSATION INSURANCE ADDRESS J30 �/• C.� G 1
(This section need not be completed if the work involved by the MANHOLE REFERENCE ��
permit is for one hundred dollars ($100) or less.) LOCALITY OWER
NEAREST 97 TYPE OF CONNECTION - LENGTH FROM
I certify that in the performance of the work for which this CROSS ST. Y URB P L M L TO P L
permit is issued, 1 shall not employ any person in any manner LEGAL P C NO
so as to become subject to the Workers' Compensat n Lows. DESCRIPTION LOT NO. CO IMP NO JOB NO
BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO
Date � `( Applicant �
NOTICE TO APPLICANT: If, aft r matin this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD IN$TR NO DATE
9 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
revoked. BUILDINGS STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION PERMIT NO
I hereby affirm that I am licensed under provisions of Chapter OWNER
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
.jr38--�LrC CHARGES
ness and Professions Code, and m,/license is in full force and
effect. CIT -17 C.l TEL.NO. CONNECTION CHARGE FEE
License Number Lic.Class REIMBURSEMENT FEE
CONTRACTOR
Contractor Date DISTRICT NO GROUP MAP PROCESSED BY
ADDRESS BK PG
❑ I am exempt under Sec, of the L.A.Co. x�� _� d
CITY TEL.NO. O
Plumbing Code and/or Sec. of rhe STATE LIC. FINAL V
LICENSE NO. CLASS DATE VALIDATION
B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE » Z
HOUSE SEWER CONNECTING TO FINAL ' •f-
Date PUBLIC SEWER BY �=
SEPTIC TANK SEEPAGE PIT OR .�
PITS AND OR DRAINFIELD _ [j�. �'
Signature 11 s'- (1)
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO
PRIVATE.DISPOSAL SYSTEM 'j --- —x Z
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR `CIT.Al. y :r' m ��5
Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER
feSSiOnS Code OVERFLOW SEEPAGE PIT DRAINRELD
EXTN,CESSPOOL.DRYWELL.MANHOLE "
1, as owner of thep p yerr 'ro Or my g as employees with wages ALTER. REPAIR OR ABANDON HOUSE -
SEWER OR DISPOSAL SYSTEM =' }''•'��= v`'�=
their sole compensation, will do the work and the structure
is not intended or offered for sale (Section 7044, Business
and Professions Code).
❑ 1,as owner of the property, am exclusively contracting with
licensed contractors to construct the project (Section 7044, OWNERS Permit $
Business and Professions Code). AUTHORIZATION TOTAL FEE 5;
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR 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
issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_
OWNER OR
Lender's Name OWNERS AGENT
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,
and hereby authorize representatives of this County to enter
upon fhe'obove-mentioned perry for inspection purposes.
Xignafur Permittee Dafev SEE REVERSE FOR EXPLANATORY LANGUAGE