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Home My Public Portal About10533 DAINES DR_Sewer__ DEPARTDIENT OF COUNTY ENGINEER SEWER=-SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY' �. PERMIT APPLICATION! COUNTY OF LOS ANGELES DING VVI Lt IAM J.rFOX. COUNTY ENGINEER. ADDRESS 'F FOR APPLICANT FILL IN LOCALITY BUILDING �' 3 (� NEAREST ADDRESS �J �✓T-�L[✓L CROSS ST. LOCALITY fP DISTRICT NO. - SERIAL NO. PERMIT NO. NEAREST A /5,D`'J I S CROSS ST - a _ RECEIVED BY Ready for Inspeoilon DATE ISSUED OWNER n iG�I 17L.. MAIL` - i. _ •. - ADDRESS - USE ZONE bb OCCUPANNsCYn BK MAP PGr CITY k TE1�.N0. /�� ` I h� V-�(�. �► r CONTRACTOR Z` ADDRESS JOB.N0. 3 - CI Y TEL.NO. TRUNK•-iRMIT NO. -a ` STATE R ISTRA ION N3 /jR e COUNTY ROAD PERM NO LEGAL DESCRIPTION OT N0. - , PERMIT NO STATE ENCROA ENT BLOCK ACT m I WASTE APPROVAL NO OF BLDG SIZE OF LOT�Q X NOW ON LOTS 1• C S-` 1 t,. ? USE OFCONNECTION CHARGE FEE BUILDINGS 9f♦±9r ' NO DESCRIPTION OF WORK` ' FEE REIMBURSEMENT FE 5 z- ti,* ' HOUSE SEWER CONNECTING T0 - ` _ PUBUCSEWER '" - 4@ $ 350 RECEIPT NO DATE B HOUSE SEWER CONNECTING TO 11 PRIVATE DISPOSAL SYSTEM 1 00 _ r CONNECT ADDITIONAL BLDG.OR' EXCEPTION RECORDED ` WORK TO HOUSE SEWER 1 00 ALTER OR REPAIR EXISTING t NO I LATE-` _ !'-4y t� \ SEWER OR DISPOSAL SYSTEM 1 00 _ DISCONNECT AND ABANDON SEWER ` _ AND/OR DISPOSAL SYSTEM 5� I Do - CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR v I - PITS AND/OR DRAINFIEL_D 2.00 STATION�-4 Q. D DEPTkH, 4 CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2 00 .tom MANHOLE REFERENCE;, 4 \� l3'P� i 1 L6WE11 TY CON E&ION ../' LENGTH FROM ' Y CURB :-IPfL. _-M L.•TO OWNERS PERMIT ; 1 00 - AUTHORIZATION - TOTAL FEE I HAVE THIS DATE CONTRACTED WITH THE THEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBEDpEXISTING APPROVALS'': INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER _ NEW HOUSE SEWER x SIGNED THIS_ __ AY OF___. .._✓t _� �___.19______ 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[] DRYWELL'� - CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR. REGULAT;NG PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM I -HEREBY CERTIFY THAT IAM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ER OF THE ABO ESCRIBED R ENTIAL PROPERTY. BACKFILL SEPTIC TANKS� L4001 "`' SEEP.PIT(S)E] CESSPOOLS El ' F ATUREY/y ERMITT _ __-�- _ _ 76A643D 663 1/53 1 _. �i WORKERS'COMPENSATION DECLARATION Lby affirm that I have a certificate of constnt to self I, or a certificate of Workers'Compensation Insurance, or 76A642D r� Pied copy thereof (Sec 3800, Lab C ) CE BOB(REV 8/811 APPLICATION FOR PERMIT No Company ®S _ rtified copy is hereby furnished SEWER - SEWAGE DISPOSAL 1 rtlfled copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY apartment -Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING S'33 d t nom, COMPENSATION INSURANCE ADDRESS �C STATION DEPTH , Iris ctlon need not be completed If the work Involved by the MANHOLE REFERENCE UPPER for one hundred dollars ($100)or less ) LOCALITY LOWER Ify that in the performance Of the work for which this NEAREROSSSST P TYPE OF CONNECTION LENGTH FROM Y CURB P L' M L TO P L t Is Issued, I shall not employ any person In any manner P c No to become subject to the Workers'Compensation Laws OWNER K� �c� S �'l61 r-a �i 1^ CO IMP NO JOB NO 0 MAIL TRUNK PERMIT NO D PERMIT NO Applicant ADDRESS 10C? ` Q y/tB S - 1/x� E TO APPLICANT If, after making ThI$ Certificate Of �}^ AFFIDAVIT WAIVER EASEME RE RD INSP DATE V I g CITY 1 TEL NO �4-�'�3�� F (tion, you should become subject to the Workers' LEGAL LU nsation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO HWY OR ST WIDENINGQ. with-such provisions o`r this permit shall'be deemed - . - - - $A -d > BLOCK TRACT OACHME/ Z ' 4 LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO SIZE OF LOT NOW ON LOT :)y affirm that I am licensed under provisions of Chapter r iUSOF mencing with Section 7000) of Division 3 of the Busl- BUILDINGS CHARGES i Ind Professions Code, and my license Is in full force and CONTRACTOR CONNECTION CHARGE FEE r _ C Number LIC Class ADDRESS REIMBURSEMENT FEE CTOr Date DISTRICT NO GROUP MAP PROCESSED BY CITY TEL NO STATE LIC BK PG �n exempt under Sec of The L A Co LICENSE NO CLASS tubing Code and/or Sec of The NO DESCRIPTION OF WORK FEE FINAL I ,HOUSE SEWER CONNECTING TO DATE 77/O 7 �� VALIDATION P Code for the following reason PUBLIC SEWER G G SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL ^ Date HOUSE SEWER,CONNECTING TO BY PRIVATE DISPOSAL SYSTEM nature CONNECT ADDITIONAL BLDG OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER ,4 y ae fOVERFLOW SEEPAGE PIT,DRAINFIELD ffEXTN,CESSPOO HOLE I th irm that I am exempt from the Contractor's License ollowing reaSon (Secton 7031 5, Buisness and Pro- ALTER,REPAI R ABANDON HOUSE'S 5 Code) SEWER OR DI A EpiLs/ ( _ G 409, O n,6 fi n iS owner of the property, or my employees with wages as 7 lir sole compensation, will do the work and The structure U # o 0 0 0 1 0- lot Intended or offered for sale (Section 7044, Business i Professions Code) OWNERpermit $S .2 0 - 21.50 1s owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE -nsed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRA(fr5R TO 10 0 o 2 1,5 0 5 liness and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 0 0 1 _ O(J Z CONSTRUCTION LENDING AGENCY , V �J y affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ performance of the work for which this permit is OWNER OR OWNERS AGENT Sec 3097, Civ C ) ADDRESS Name Address 'f ' that I have read this application and state that the nformation Is correct I agree to comply with all County i ices and State jaws regulating Plumbing and Sewers, " d feby authorize representatives of this,'County to,enter ve-mentioned property for ins ection purposes -- f oture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE r