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HomeMy Public PortalAbout6028 CLOVERLY AVE_Sewer__ DEPARTMENT OF COUNTY EN(iINEF.)Ei SEWER-SEWAGE DISPOSAL i'44DIVISION OF BUILDING AND SAF= PERMIT APPLICATION COUNTY OF LOS ANGF2 / WILLIAM J. FOX. COUNTY ENGIN[eR jl BUILDING ADDRESS_ �J /aU�Y /p-,VADDRESS J FOR APPLI ANT TO FILL IN LocALITY - BUILDING NEAREST /� O r V 7`7'"r ADDRESS CROSS ST V`� LOCALITY DISTRICT NO I Ready for Inspection PERMIT NO NEAREST A / © r Lr i S 4 (Q 8 s CROSS ST V V �� / DATE G Psi ✓ /j !/1 % CEIV T7 T I ISSUED OWNER �/ MAIL USE ZONE OCCUPANCY MAP ADDRESS BK PG CITY TEL NO CONTRACTOR CO IMP NO ADDRESS 81 Q "1 _ JOB NO \ CITY TEL NO/6,A, 15:4 1, TRUNK PERMIT NO i REGISTRATION NO J f q L COUNTY ROAD PERMIT NO g 70LEGAL Gj / DESCRIPTION LOT NO STATE ENCROACHMENT PERMIT NO BLOCK TRACT s 6/ INDUSTRIAL -------- WASTE APPROVAL SIZE OF LOT -a /3s QN100,ON LOTS \ CHARGES / BSOF UE DINGS CONNECTION.QHARGE FEE / NO DESCRIPTION OF WORK FEE ! / THOUSE SEWER CONNECTING TO C � REIMBURSEMENT FEES PUBLICSEWER @ $ 358 _LI RECEIPT NO I DATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED _ WORK TO HOUSE SEWER - 1 00 ALTER OR REPAIR EXISTING NO I DATE lI•B`, \ SEWER OR DISPOSAL SYSTEM 100 DISCONNECT AND ABANDON SEWER _ AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA SEPTIC TANK SEEPAGE PIT OR p/ ,t PITS AND/OR DRAINFIELD 200 STATION 7/-S6.D DEPTH CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2 00 �/ �( / MA HOPEI� REFERENCE LOWER TYPE OF CONN C LENGTH FROM OWNERS PERMIT $ 1 00 Y CURB P L M L TO P L AUTHORIZATION TOTAL FEE tl 156 IHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS _ AY OF- f_____I_ _l9 NEW HOUSE SEWER -'?-{� _ OWNER 0R 1 CONNECT ADDITIONAL OWNERS AGENT ���llf SSS________ _ �, BUILDING OR WORK t SEPTIC TANK SEEP PIT(S) ADDRESS AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[:] 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 I] t SIGNATURE `2 ' j��,� SEEP PIT(S)[] CESSPOOLS[] OF PERMITTEE Z /✓dN-�+Av — _ 76A842D S&E 663 4/54 f A WORKERS COMPENSATION DECLARATION �i 1 hereby affirm that I have a certificate of consent to self 20D05tDPWst69 U Insure or a cgrtrficate of Workers Compensation Insurance or 76A642D a certified 'copy thereof (Sec 3800 Lab C ) APPLICATION FOR PERMIT Policy No Company Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL F-1 ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS \ 1� COMPENSATION INSURANCE ADDRESS _.i G V STATION f�G Q DEPTH (This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE OWER permit Is for one hundred dollars ($100) or less ) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST Y CURB PL 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 CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant NOTICE TO APPLICANT If after makingthis Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE 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 5T WIDENING comply with such provisions or this permit shall be deemed USE OF revoked BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION I` PERMIT No I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Bu sl MAIL f V ADDRESS i—[9 11 TIZ Ly CHARGES ness and Professions Code and my license is In full force and effect CITY TEL No 1 CONNECTION CHARGE FEE License Number LIC ClosS V REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED BY ADDRESS BK PG ❑ I am exempt under Sec of the L A Co �� a CITY TEL NO Q Plumbing Code and/Or Sec of the STATE LIC FINAL U LICENSE NO CLASS DATE VALIDATION Z� B 8 P Code for the following reason NO I DESCRIPTION OF WORK FEE r _ O HOUSE SEWER CONNECTING TO FINAL X11 Date PUBLIC SEWER BY / a SEPTIC TANK SEEPAGE PIT OR / _ 1 4,g, Signature Pi TS AND OR DRAINFIELD (� W g OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING To ® _.JL< _ PRIVATE DISPOSAL SYSTEM V I hereby affirm that I am exempt from the Contractor s License CONNECT ADDITIONAL BLDG OR4 /J I —i7_ Law for the following reason (Secton 7031 5 Buisness and Pro WORK TO HOUSE SEWER r7S lam- 1 I E.. D fe5510 n5 Code OVERFLOW SEEPAGE PIT GRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE .0 riL `_55 ® .L5 ❑ I as owner of the property or my employees with wages as ALTER REPAIR OR ABANDON HOUSE i SS e 7i= their sole compensation will do the work and the structure SEWER OR DISPOSAL SYSTEM HE Is not intended or offered for sale (Section 7044 Business `3L_ and e!",s; and Professions Code) ❑ 1 as owner of the property am exclusively contracting with licensed contractors to construct the project (Section 7044 OWNER'S Permit $ ICONTRACTOR Business and Professions Code) AUTHORIZATION TOTAL FEE `CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED I hereby affirm that there Is a construction lending agencyCONNECT THE ABOVE DESCRIBED EXISTING DNELLING TO THE PUBfor the performance of the work for which this permit Is Issued (Sec 3097 Civ C ) SIGNED THIS DAY OF 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 jaws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes Signature o ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE