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Home My Public Portal About10206 DAINES DR_Sewer__ DEPARTDiENT OF COUNTY ENGINEER i SEWER-SEWAGE DISPOSAL 19 211 DIVISION OF BUILDING AND SAFETY f PERMIT APPLICATION COUNTY OF LOS ANGELES - WILLIAM J. FOX, COUNTY ENGINEER BUILDING ADDRESS 1 FOR APPLICANT TQ FILL INLOCALITY BUILDING NEAREST ADDREon SS �Q Q�(/d/(�,� CROSS ST. Cwt. DISTRICT NOV SERIAL NO. PERMIT NO. LOCALITY f- A /e O j4-7 S NEAREST /� /1 CROSS ST. l/ RECEIVEDiBy Ready for Inspection DATE ISSUED OWNER MAIL ` ADDRESS / USE ZONE OCCUPANCY BK MAP PG CITY TELAO. CONTRACTOR California Sewer CoI1S't.. ('.A_ CO.IMP.NO. yC ADDRESS 1317 Colegrove Ave, JOB.NO. CITY Montebello TEL.NO.UNlon 1-5048 TRUNK PERMIT NO. � STATE REGISTRATION NO. 104445 $ C(PgNTY ROAD PERMIT NO. LEGAL DESCRIPTION LOT NO. STATE ENCROACHMENT 'dS PERMIT NO. BLOCK TRACT INDUSTRIAL WASTE APPROVAL SIZE OF LOT .2N0.OF BLDGS. CHARGES u NOW ON LOT USE OF `Y� - CONNECTION CHARGE FEE BUILDINGS NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT FE ' PUBLICSEWER @ $ 3.50 RECEIPT NO. I ATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECOR D ` WORK'TO HOUSE SEWER 1.00 / NO ALTER OR REPAIR EXISTING DATE BY SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER - AND/OR DISPOSAL SYSTEM - 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR / PITS AND/OR DRAINFIELD- 2.00 STATION U U Q DEPTH 9 CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2.00 / MANHOLE REFERENCE ;S"�.6� E UPPER 7.pgv TYPE OF CONNECTIOLENGTH FROM OWNERS '`-- Cts P.L. M L.TO P L. Z S PERMIT ; I I 00 AUTHORIZATION I TOTAL FEE , I HAVE 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 CTo E)Q -1953 NEW HOUSE SEWER OWNER OR - - CONNECT ADDITIONAL OWNERS AGENT _ -•• BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) ADDRESS........ AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL I] DRYWELL CATION AND STATE THAT THE ABOVE 18 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 DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ER OF THE ABOVE DESCRI D RE DENTIAL PROPERTY. BACKFILL SEPTIC TANKS SIGNATURE SEEP.PIT(S)[D CESSPOOLS C c-L -OG 11-3 573 OF PERMITTEE _.. ... -_ 76A642A 663 7/53 P n WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 92'0002 DPW 3/87 ;. insure, or a cgrtificate of Workers' Compensation Insurance, or D certified copy thereof (Sec 3$D0, Lab C ) `E CE 8 80� APPLICATION FOR PERMIT tolicy No ICompany Os ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ 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' BUILDING c� COMPENSATION INSURANCE ADDRESS V LC STATION DEPTH1��-C (This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less ) LOCALITY LOWER I certify that in the performance of the work for which this CRpu ST - /eK _ t�`J TYPE OF CONNECTION LENGTH FROM Y CURB P l ML TOP L permit is Issued, 1 shall not employ any person In any manner so as to become subject to the Wor s'-Compensation Laws P c NO OWNER � 'L CO IMP NO JOB NO ` MAIL TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS -' NOTE TO PPLICANT If, after making this Certificate of CITY TEL NO 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 LOT CONTRACTORS DECLARATION NO of PERMIT NO - 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 BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect CONTRACTOR (�7 w CONNECTION CHARGE FEE Q G } License Number A'J / LIC Class 3 ADDRESS _7? Q� �I//`�/ 7 REIMBURSEMENT FEE O ContractOr-� 'J � _ Aate Z�/ r b CITY / i TEL NO �O A / 1-3 CJ DISTRICT NO GROUP MAP PROCESSED BY O �) / ? �Jj BK PG Z ' STATE• �SV S Z CLASS Cr U 0V �/ ❑ I am exempt under Sec of the L A Co LICENSE NO �l // NO DESCRIPTION OF WORK FEE Plumbing Code and/or Sec of the FINAL W HOUSE SEWER CONNECTING TO DATE VALIDATI PUBLIC SEWER M B 8 P Code for the following reason v) SEPTIC TANK,SEEPAGE PIT OR FIN Z " PITS AND/OR DRAINFIELD Date , HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature I/ CONNECT ADDITIONAL BLDG OR , OWNER-BUILDER DECLARATION' fC WORK To HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD If ' I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031 5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE g 8 8 at1 A fessions Code) SEWER OR DISPOSAL SYSTEM ❑ 1,as owner of the property, or my employees with wages as #.0 0 0 0-;1 .Q their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business Permit $ ( °,°2.1.5 0 and Professions Code) OWNER'S ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE - o o.0 215 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 0 1,25t88 CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this perm It is OWNER OR OWNERS AGENT issued (Sec 3097, Civ C ) ADDRESS Lender's Name - Lender's 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 bove-mentio ed property for inspection purposes / Z3� Signature of Permittee Dae SEE REVERSE FOR EXPLANATORY LANGUAGE r