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HomeMy Public PortalAbout10252 DAINES DR_Sewer__ COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0502040001 BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: SEWERLEGAL ID: SEWER / SEPTIC: G . TR: 15862 LT: 10 EXIST OCC GRP: 10252 DAINES DR . BLDGS. NOW ON LOT: - TEMP CA 917802707 ASSESSORNUMBER: CONNECTION TYPE: NEAREST CROSS STREET: ARDEN 8586-027-010 ORIGINATION: THOMAS PAGE: 597 GRID: B3 LOCALITY: TEMPLE CITY, C LENGTH ML TO PL: STATION: DEPTH: MANHOLE REFERENCE: -- UPPER/LOWER: S . 02/04/05 JK 08/03/05 COUNTY IMPROVEMENT NUMBER: TE PLAN CHECK NUMBER: FI E CODE: MACH SUSAN (626) 448-6423- JOB NUMBER: 10252 DAINES DR TRUNK PERMIT NUMBER: TEMP 917802707 ROAD PERMIT NUMBER: R AFFADAVIT: NO CO NECT RESIDENCE TO PUBLIC SEWER WAIVER: NO APPLICANT: TEL. . EASEMENT: NO SAME AS OWNER - RECORD INSTRUMENT NBR: RECORD DATE: SPECIAL CONDITIONS: HIGHWAY/STREET WIDENING: STATE ENCROACHMENT PERMIT NUMBER: CONTRACTOR: TEL. NO: FEES PAID APPROVALS DATE INSPECTOR SIGNATURE SAME AS OWNER - LIC. NO FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: NEW HOUSE 01 PERMIT ISSUANCE FEE 27.75 CECT ADDITIONAL 03 CONN TO PUBLIC SEWER 1.00 CON 46.95 BUILDING OR WORK ARCHITEC TOTAL FEES 74.70 Stellu IANK, SEEPAGE PIT LIC. NO: AND/OR DRAIN FIELD DR�4 SEWEREPAIR, EWER R SEWAGE DISPOSAL EM DISCONNECT ABANDON HOUSE SEWER BACKFILL SEPTIC TNWR'§— SEEP. PIT CESSPOOL SYSTEMGRAYWATER REPORT ID: OPR266 ROUTE TO SS0508 r 'WORKERS'COMPENSATION DE,-LARATION h;=ebyiaffirm that I have a certificate of consent to self ins ure,'or o'certificate of Workers'Compensation Insurance, or 76A6421) a �ertified copy thereof (Sec 3800, Lab C > CE 808(REV B/B,) APPLICATION FOR PERMIT Policy icy No Company Os , ❑ Ce;lified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING'ANb,SAFETY department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /a Z ��I Nis n/1 STATION DEPTH �Q , COMPENSATION INSURANCE ADDRESS 2,5 iR 1 (This section need not be completed If the work Involved by the MANHOLE REFERENCE `sf- UPPER LOCALITY / permit is for one hundred dollars ($100)or less')'� • _ LOWER- NEAREST - TYPE OF CONNECTION LENGTH FROM I certify that m the performarice of the work for which this CROSS ST ZA'V i N �� V CURB• P L ML TOP L permit Is Issued, I shall not employ any person In any manner- so as to become subject'to the Workers'Compensation Laws P C NO ,�/ OWNER ,L'Jl! A CO IMP NOJAE JOB NO' 1'I) _1 /'yf MAIL /�,a �}� TRUNK PERMIT NO ROAD PERMIT NO Date lJ(T Applicant ADDRESS SAM�' A S ,TI Y t3 ' NOTICE TO APPLICANT If, after makin th I$ Certrficate Of �7 ` AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g CITY TEL NO / dC LJ _ - 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 BUST- BUILDINGS CHARGES ness and Professions Code, and my license Is In full'force and effect CONTRACTOR CONNECTION CHARGE FEE License Number LIC Class 4. ADDRESSIIIREIMBURSEMENT FEE Q ' Contractor Date DISTRICT NO GROUP MAP Pp ESSED BY L.7 _ CITY TEL NO BK PG Z STATE LIC !O� L O ❑ I am exempt under Sec of the L A Co LICENSE NO cuass H NO DESCRIPTION OF WORK FEE Plumbing Code and/or Sec of the FINAL ULU ' - HOUSE SEWER CONNECTING TOQ DATE VALIDATION CL SEWER B 8 P Code for the following reason PUBLIC Z ' SEPTIC TANK,SEEPAGE PIT OR FINAL PITS"AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM s Signature WCONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER INIELD I hereby affirm that I am exempt from the Contractor's License EOVERXTN FLOC SS EPOOLGDRYWELL,MAFNHOLE t Law for the following reason (Sefton 7031 S, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE 10 fessions Code) SEWER OR DISPOSAL SYSTEM �+��++ ❑ I,as owner of the property,or my employees with wages as ACCT.0 their sole compensation, will do the work and the structure 33�nn] \ Is not intended or offered for sale (Section 7044, Business >73V• ntd27.50 Aand Professions Code) OWNER'S Permit- $ 1 ITEM I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL kcensed'contractors to construct the project'(Section 7044, 1 HAVE AT'THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR-To 27. 5C) Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY ,/7� 27.50 I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF_// /�� for the performance of the work for which this 'permit Is OWNER OR � ui�7 ISSUed (Sec 3097, CIV C ) OWNERS AGENT ' Lender's Name ADDRESS� ' Lender's Address 304'81 AM 8:42 1 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 the abo e nentioned property for Inspection pur f�oses Signatu of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self nsure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No. Company ©s ElCertified 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 COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers Compensation Laws. P.C. NO. I P OWNER CO IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL NO, AFFIDAVIT WAIVER EASEMENT RECORDINSTR.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 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 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 Contractor DateCITDISTRICT NO. GROUP MAP PROCESSED BY U TEL.NO. BK PG El am exem t under Sec. of the L.A.Co. STATE CL P LICENSE NO. CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEEL HOUSE SEWER CONNECTING TO DATE VALIDATION PUBLIC SEWER B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION IWORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN.,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 ❑ 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 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. CONSTRUCTION LENDING AGENCY poll.I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, CIV. C.). OWNERS AGENT 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 the above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE