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Home My Public Portal About10632 DAINES DR_Sewer__ WORKERS' COMPENSATION DECLARATION DPW 6I89 Insure. or 0o5t I hereby affirm that I have o certificate of consent to self p0200051D a certificate of Workers' Compensation Insurance, or a certified copy Thereof (Sen 3800, Lob C.) APPLICATION FOR PERMIT Policy Na. .. e company SEWER - SEWAGE DISPOSAL C1 Certified copy is hereby furnished. Certified copy is filed with the cope buil ing inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Y tl e�parl/*'en Dote/ �AppGmm FOR APPLICANT TO FILL IN CONNECTION DATA CE LATE OF EXEMPTI N FROM WORKERS' BUILDING ``� STATION DEPTH COMPENSATION INSURANCE Apo RESs ✓f7 Z lex ( completed ie workinvolved by MANHOLE REFERENCE This section need not be Com lf the the LOCALITY UPPER permit is for one hundred dollars (8100)or less.) LOWER NE ST CURB TYPE OF'CO ON I, LENGTH FROM certify that in the performance of the work for which This CROBS ST R . 12 Y CURB PL ML TORI permit is Issued. I shall not employ any person in any manner LEGAL P C NO so as to become subject to the Workers'Compensation Lows, DESCRIPTION LOT NO. CO IMP NO FOB No Date Applicam BLOCK TRACT TRUNKPERMIT NO ROAD PERMIT NO ASSESSOR AFFIDAVIT WAVER EASEMENT RECORD INSTR NO DATE NOTICE n, APPLICANT: If, after making this CeNi Work oT MAPBOOK PAGE PARCEL Exemption, you should become subject to the Workers No.OF FIDES. - Compensation provisions of the Labor code. you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed fADDRESS OE revoked. DINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter NER le 9 (commencing with Section 7000) of Division 3 of the Brsli L ness and Professions Code, and Ni license is in full force and ati CHARGES effect /1' CITY TEL,NO. CONNECTION CHARGE FEE License No O `� LiC C a55 7 REIMBURSEMENT FEE r CONTRACTOR n ifr"Qyt Contractor k— Date v C .yam — DISTRICT NO GROUP MAPG PROCESSED BY ADDRESS Fir QI am exempt under SecIME,L.A. Co. CITY - TE y/d c 71 6 r[) �� -3 P d O Plumbing Code and/or Sec. of the STATE / 99 �� _ LIG FINAL U LICENSE NO. 6� �Y�" CLAss DATE r VALIDATION Z B. 8 P. Code for the following reason NO. DescRlPn of woRK FEEC� HOUSE SEWER CONNECTING TO FINAL T —� 1� O DaIE PUBIC$f'NEF BY ACCT.A W _ SEPTIC TANK SEEPAGE PIT OR Signature PITS AND OR DRAINFIELD (a� g HOUSE SEWER CONNECTING TO 3303 x,7.29 OWNERBUILDERDECLARATION PRIVATE DISPOSAL SYSTEM - I hereby affirm that I am exempt from the Contractor's License CONNECT ADCmONmTl4�OR ?�' a 1 ITEMS Low for the following reason (Secton 7031.5, Buisness and Pro- "` R �C 1 �p �3 fessions Code): OVERFLOW SEEPAGE PIT DRAINFIELD _ TOTAL C Y n 20 ExTN,CESSPOOL DRYWELL MANHOLE 4TER, REPAIR OR ABANDON HOUSE (�I-EC 57.20❑ I,their owner of the property,will o employees with wages re SEWER OR DISPOSAL SYSTEM CHECK -t7•71-f their sole compensation, will s the work and the structure _ CHANGE .00 is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ I,as owner of the property, am exclusively contracting with licensed contractors TO Construct the project (Section 7044, OWNER'S Permit $ Q 0000_0001 3/ 6/96 Business and Professions Code), AUTHORIZATION TOTAL FEE Q 5173 1 PM 632 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CCN FACTOR TO I hereby affirm that there i5 a Construction lending agency CONNECT THE ABOVE DESCPIefD EXISTING DWELLING To THE PUBLIC SEWER for the performance of the work for which this permit Is issued (Sec. 3097, Civ. C. SIGNED THIS DAY DF 19_ OWNER OR Lender's Name OWNF RS AGENT Lender's Address ADDRESS I certify that I have read this application and state thot the above information Is correct I agree to Comply with oil County ordinances and State laws regulating Plumbing and Sewers, and hereby ayyyhoroa representatives of this County to enter upon the b be-mentioned property far ins eCHOn_purposes. _ . /�� I o Re rm l t tee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE � T.Ae.aD 888q APPLICATION FOR PER , CE80� COUNTY OF LOS ANGELESSEWER—SEWAGE DISPO AL DEPARTMENT OF COUNTY ENGINEER - BUILDING AND SAFETY DIVISION em LDING .� f !- ADDRESS JOHN A. LAINSIE,GRIFFI County. Eng�as�r elll Y CASSATS D. GRIFFIN, Sup t of 8uildinq LOCALITY NEAREST FOR APPLICANT T)O FULL IN CROSS ST.LEGAL / DESCRIPTION LOT NO. ?O A C rr /! OWNER / BLOCK TRACT C•7 G fI MAIL J (i ADDRESS NO.OF BLOBS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT N0. GROUP BK MAP PG PROCESSE BY CONTRACTOR / �M O L' O z J ADDRESS oG�� a LP N .0 �IECON DATA CITY b TEL.NO. —ll��' ION D DEPTH �` v Z STATE MANHOLE REFERENC REGISTRATION N0. B COUNTY /*fOWEllo No. I DESCRIPTION OF WORK FEE z& HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 OO TYPE OF CONNECTION LENGTH FROM F % SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. PITS AND/DR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELDa ad EXTN.. CESSPOOL. D RYWELL@ $2.00 PRIVATE DSE SEVI SPOSAL SYSTEM ER CONNECTINGTO @ $1.00 - CO.IMP. N0. > JOB NO. CONNECT ADDITIONAL BLDG.OR ORK TO HOUSE SEWER $1.00 TRUNK PERMIT N0. ROAD PERMIT N0. W SEWERREPAIR P DIISPOSAL SYSTEM HOUSE @ SI00STATE ENCROACHMENT PERMIT NO. INDUSTRIAL f WASTE APPROVAL CHARGES OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS D TE INSPECTO{t'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19_ xew HOUSE SEweR OWNER OR .-�cN- 1 CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) .AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. ALTER,REPAIR.SEWER OR SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR SEWAGE NEC DISPOSAL AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT ISCON NET PLUGA D CALIFORNIA OR THAT I AM THE LEGAL OWNER F THE ABOVE DESCRIBED RESIDE 1 L P OP /g I A BACKFLL SEPTIC TANKS [ISIGNATURE ,{/ry(/ly(,,/ SEEP. PIT LLS ❑ CESSPOOLS [IG OF PERMITTE //2T.. �O - ®r / gALIDATION ROBERT A. WOOD CK. M.u. EAaB SUPERVISING MECHANICAL ENGINEER n 5-00 I a 0p 7 9 4 � J Fa i U K 0 CE80a APPLICATION FOR PER IT eeo�e.8a COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER A I 1 19 - BUILDING AND SAFETY DIVISION BUILDING / / J c IOHN A, LAMBIE, County weer ADDRESS a ` - CASSASY D. GRIFFIN, Sup I of Building LOCALITY P NEAREST FOR P116jW LEGAL TO FL IN CROSS sr. DESCRIPTIW/ gOV/CZ l Zel /f T' BLOCK TRACT MAIL ADDRESS N0.OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS I DISTRICT [N OOJ GRRJO-UPBK MAP PG PROCESS DBY CONTRACTOR c ADDRESS D7 P ✓e CONNECTIONCDJATA vu CITY 4/ L.NO. -Z �/ TION O DEPTH/Q / p REGISTRATION NO. f2 _-3U /O 2- COUNTY MANHOLE REFEREN C 3IA/ 0 E NO. DESCRIPTION OF WORK FEE YY' HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM C SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. .J PITS AND/OR DRAINFIELD @ $3.00 / OVERFLOW SEEPAGE PIT, DRAINFIELD EXTH..CESSPOOL. DRYWELL @ S2.00 HOUSE SEWER CONNECTING TO _ P.C.N0. @ 51.00 PRIVATE DISPOSAL SYSTEM @ SLOB CO.IMP. NO. JOB N0. CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. s f WORK TO HOUSE SEWER ALTER,REPAIR OR ABANDDN HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES o OVVNER'S PERMIT .�,, ��11 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE TV REI MBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19_ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK i�.✓� /V ADDRESS LALTER.REPAIR, TANK,SEEP.PIT(S) J / ' n �/ If DRAINFIELD I b �� 1/ red 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIONJ� p AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYOL ❑ DRYWELL ❑ �/V/ '.i V WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGREPAIR,SEWER ORPLUMBING AND SEWERS. DISPOS SEWER EMI HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/ORNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFN HOUSE SEWER CALIFORNIA OR THAT I AM T LEGAL OWNER OF THE ABOVEDESCRIBED RESIDENT PROPE Y.`kILL SE PT IC TSIGNATURE ///C � ITS ❑ CESSPOOLS OF PERMITTEE- l I ®' -- / AL P/+SINGMROBERT A. WOOD CK. Y..0. CASH o. SUPERVISING MECHANICAL ENGINEER LA-1-00 7 9 5 0 JiMi D 1 1 0 2 5.0 0