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Home My Public Portal About6023 CLOVERLY AVE_Sewer__ D 5&E 0633 SB ■APPLICATION FOR PERMIT _ 1 8 DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL Department of County Engmeer County of Los Angeles BUILDING WM J. FOX, COUNTY ENGINEER ADDRESSfL' CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITYEAREST Y FOR APPLICA T TO FILL IN CROSS ST DESCRIPTION LOT NO OWNER 0-"' sLEGAL /6� J BLOCK TRACT MAILADDRESS Gh-�L�IiL NO OF BLDGS / SIZE OF LOT ,. V- I ® NOW ON LOT CITY TEL NO USE OF -1r!5? F BUILDINGS 11 5. DISTRICT NO GROUP MAP CONTRACTOR ADDRESS CONNECTION DATA w/ CITY TEL NO �� J STATION DEPTH (, STATE MANHOLE REFERENCE REGISTRATION NO ` ❑ COUNTY �I/ d J LOWER No DESCRIPTION OF WORK FEE TYPE OF CONNE ON LENGTH FROM �] HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L _ PUBLIC SEWER Q $ 3 50 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1 00 _ CONNECT ADDITIONAL BLDG OR P C NO WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO 7 DISCONNECT AND ABANDON SEWER STATF ENCROACHMENT AMD/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 $ 1 00 AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE CON TRACTOR T OS CONNECTO THE ABOVE DESCRIBED EXISTINGWITH THE HEREINAIJED DWELLING APPROVALS DATE INSPECTOR S SIGNATURE TO THE PUBLIC S W R �,/� q/ � L NEW HOUSE SEWER HIS g SIGNED TDAY OF 19 OWNER CONNECT ADDITIONAL v y OWNERS /AGENT I ( �/'�'"'- - BUILDING OR WORK b O 3 �J 0 V C ✓' )LA-d �+ SEPTIC TANK SEEP PITS) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ T IS APPLICATION CESSPOOL❑ DRYWELL[:1AND 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 IHEREBY CERTIFY THAT I AM PROPERLY REGIS ERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COU 'AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT 1 AM THE LE L 0 ER OF THE ABOIE ABANDON HOUSE SEWER DESCRIBED RESIDENTIA ROPERTY / BACKFILL SEPTIC TANKS❑ o SEEP PIT(S) ❑ CESSPOOLS &7, SIGNATURE OF PERMITTEE,,, WILLIAM J.FOX.Com TY ENGINEER l I MATION R A WOOD, CHIEF FLBG ANSPECTOR f jAC5 5 3 7'09 PPR2 7 4 4.5 0 tn �. WORKERS COMPENSATION DECLARATION , 11 hereby affirm that I have a certificate of consent to self _ - insure, or a certificate of Workers Compensation Insurance or 7sAsazD p a,certlfl1 6 py t e f Sec 3800, Lab � 920002 DPW 6/158 APPLICATION FOR PERMIT Policy N mpany L Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL ^Certified copy is filed with the county building Inspection- COUNTY OF LOS ANGELES BUILDING AND SAFETY d artmeni LI Dat ' O Applicant :30611114- i</ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING / STATION DEPTH' COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by the r MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less ) LOCALITY LOWER NEAREST TYPE OF CON LENGTH FROM I certify that in the performance of the work for which this CROSSST � Y cLtRB P L ML TOP L permit is Issued, I shall not employ any person In any manner so as to become subject to the Workers Compensation Laws OWNER r G NO CO IMP NO TOB NO � - MAIL w /_ -/� ( TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS (�! C G 1n. - NOTICE TO APPLICANT If, after making this Certificate of CITY .(f- TEL NO '5;1673 Q� AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE- Exemption, you should become subject to, the Workers', LEGAL Compensation provisions of the Labor code,'you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF PERMIT NO LOT SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS tiT CHARGES ness and Professions Code, and my license is In full force and effect `' ` p`/ /�// CONTRACTOR CONNECTION CHARGE FEE License Number/ l� J LIC Class /T G /� ADDRESS REIMBURSEMENT FEE i _ i DISTRICT NO' GROUP MAP ROCESSED BY Contract Date�"J`� f 7 CITY .C � TEL NO � � V BK i ❑ I am exempt under Sec i _of the L A Co LICENSE NO STATE LIC C— IL NO DESCRIPTION OF WORK FEE 0 Plumbing Code and/or Sec of the FINAL U HOUSE SEWER CONNECTING TO DATE / VALIDATION IY B 8 P Code for the following reason PUBLIC SEWER _SEPTIC TANK SEEPAGE PIT OR FINAL O PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY r W PRIVATE DISPOSAL SYSTEMIfA - a Signature CONNECT ADDITIONAL BLDG OR to TO HOUSE SEWER OWNER-BUILDER DECLARATION WORK Z OVERFLOW SEEPAGE PIT DRAINFIELD + I hereby affirm that I am exempt from the Contractor's License EXTN CESSPOOL DRYWELL MANHOLE {� Low for the following reason (Secton 7031 5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE 1 fessions Code) EWER OR DISPOSAL SYSTEM 8 ^ AM, s El 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure M07 - 21.% is not intended or offered for sale (Section 7044'Business and Professions Code) OWNERS Permit $ ITEMS ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 21. 50 licensed contractors to construct the project (Section 7044,, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHECK 21.50 CONSTRUCTION LENDING AGENCY ►4/ 1 hereby affirm that there Is a construction lending agency SIGNED THIS DA 1 - ® CHANGE .00 for the performance of the work for which this permit Is OWNER A P P OWNERS AGENT Issued (Sec 3097, Civ C ) Lender s Name ADDRESS 0000-CW 1 11/ 3/u9 Lender s Address 6547 1 AN 8:26 1 certify that I have read this application and state that the above information is correct I agree to comply with all County ordinances d State law regulating Plumbing and Sewers and hereby uthorize r eSentatives of this County to enter U he ove-me I d roperty for Inspection purposes C_/A // 3 Ignature of er Ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS COMPENSATION DECLARATION I hereby affirm that I hate a certificcgte of,consent to self LL Insure, or a certificate of Workers Compensation Insurance or 76A642D a ceolfled copy thereof (Sec 3800, Lab C > 920002 DPW 6/88 APPLICATION FOR PERMIT � Policy-Nc{Q��2!?f Company ' XICertified copy Is hereby furnished SEWER --SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY U department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING COMPENSATION INSURANCE ADDRESS 6 (/ STATION DEPTH (This section need not be completed if the work Involved by theLOCALITY - MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less ) LOWER I certify that in the performance Of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROMCROSS ST Y CURB P L ML TOPIL permit is Issued, I shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws OWNERCO IMP NO toe NO NAIL Azz TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS NOTICE TO APPLICANT If after making this Certificate of CITY TEL NO AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE Exemption you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NOSIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE 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 effect CONTRACTOR CONNECTION CHARGE FEE License Number LIC Class ` ADDRESS , REIMBURSEMENT FEE `� �� G DISTRICT N GROUP MAP PROCESSED BY Contractor Date CITY NTEL O a -� BK PG >. ❑ I am exempt under Sec of the L A CoLICENSE NO ?j CLLASS �6 3CL _ Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEEFINA HOUSE SEWER CONNECTING TO O DAT VALIDATION B 8 P Code for the following reason PUBLIC SEWER SEPTIC TANK SEEPAGE PIT OR 0 PITS AND/OR DRAINFIELD FIN A U Date HOUSE SEWER CONNECTING TO BY W PRIVATE DISPOSAL SYSTE CL CONNECT ADDITIONAL BLDG OR ® TL OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER z OVERFLOW SEEPAGE PIT DRAINFIELD 1 hereby affirm that I am exempt from the Contractors License EXTN 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 try E:1f 1,as owner of the property,or my employees with wages as A[CT.4 their sole compensation, will do the work and the structure Is not intended or offered for sale (Section 70 44, Business - J�307 �i'7/ail and Professions Code) i N OWNER'S Permit g ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE W7, 5U 1 ITEMS licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED O RACTOR TO TOTAL m --r� Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY u /t, 27^} .�0 I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19� CHECK ' for the performance of the work for which this permit is OWNER OR OWNERS AGEN Cfil'U`I Oct. issued (Sec 3097 Civ C ) _ ADDRESS Lender s Name �y y } Lender s Address 0000-1.tu01 11/15/E9 I certify that I have read this application and state that the 6816 1 AMID-1,4 above Information is correct I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, I and ereby authorize rep s try of this County to enter up t��Ve- r e or Inspection purposes l�I� ignature o rm ittee if Date SEE REVERSE FOR EXPLANATORY LANGUAGE