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Home My Public Portal About10634 DAINES DR_Sewer__ fl, // r^� z6 CE508B-BO APPLICATION FOR PEF Mlt EBDB 11 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 2115 DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION - Bm LUING / 6 PS ADDRESS JOHN A. GRIFFIIE. County, Supt IlEof Build!OGr / CASBAT'I D. GRIFFIN, Supt of BwldiaQ LOCALITY L NEAREST FOR APP11If CROSS IWANT TJO)FI�L/L INLEAL capss sr. n DESC RGPTION LOT NO.{ O /8i .(-.�+1� /r OWNER / 'C BLOCK TRACT MAIL ADDRESS NO.OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS p DISTRI' I I CT N0. GROUP MAP PftOCES BY BK PG CONTRACTOR s� 0�S ADDRESS 2 Q �PAle CONNECTION DATA CITYS,, 1 j�/ A.j )y.,,TEL.NO. '3/—GJ�S3 STATION DEPTH w� H_ STATE MANHOLE REFERENCE REGISTRATION N0. C b Z COUNTY (::COWtR NO. DESCRIPTION OF WORK FEE / HOUSE SEWER CONNECTING TOAd PUBLIC SEWER @ $3.00 Q� TYPE OF CONNECTION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P. . PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL. DRYWELL @ $2.00 o HOUSE SEWER CONNECTING TO P.C.N0. PRIVATE DISPOSAL SYSTEM @ $1.00 - CO.IMP. NO. /337 JOB N0. J- CONNECT ApO1T10NAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. , �I WORK TO HOUSE SEWER @ $1.00 ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ !2� 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE ' JD REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON10 - TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS D E INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. ORS ,{ CE SIGNED THIS DAY OF 19_ NEW HOUSE SEWER / // /'X}SZ•f,.Jll��..._._ OWNER OR CONNECT ADDITIONAL / V OWNERS AGENT BUILDINGORWORK ADDRESS SEPTIC TANK,SEEP.PIT(S) LDISPOSAL RAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGEPAIR,SEWER OR PLUMBING AND SEWERS. DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORECT PLUG ANDLICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CT PLUGEWERCALIFORNIA 00. THAT I AM THE LEGAL OWNER OF THE ABOVEHOUSE DESCRIBED RESIDEN A PROPE}[TYa� / // L SEPTIC TANKS ❑ SIGNATUREIS) ❑ CESSPOOLS OF PERMITTEE �r 1{I,II)f{'I'I0N ROBERT A. WOOD � CK, M.o. CASH SUPERVISING MECHANICAL ENGINEER 41"' 0 7 9 6 a 011 ^y 1 0 D 5 .0 0 m TeAsazo APPLICATION FOR PEkMIT cseoe a.se COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL � 1 DEPARTMENT OF COUNTY ENGINEER - - RUILDING AND SAFETY DIVISION a�oaEssG 06 TORN A. LAMBIE, CouotF Engineer �/ CASSATT D. GRIFFIN, Sup t of Building Lola LiTY -P "./� ommr NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL 1 DESCRIPTION LOT N0. • Q OWNER (P� BLOCK TRACT MAILADDRESS NO.OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF Mpg Mm M BUILDINGS DISTRICT N0. GROUP MAP PRO�CJESSE Y I�� / BK PG CONTRACTOR 1O,EJ JT 0� / I ADDRESS Y< -4 p.P P � Q CONNNNECTION DATA CIT ,, TEL.NO. l'—� ATION � DEPTH�O r 6 / �/�j 2 CUNTY MANHOLE REFERENCES a OWER REGISTRATION N0. J L/ NO. DESCRIPTION OF WORK FEE i HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 -TYPE OF CONNECTION LENGTH FROM / SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO FROM SEPTIC PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN..CESSPOOL. DRYW ELL @ $2.00 HOUSE SEWER CONNECTING TO P.C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 r CO.IMP. NO. JOB NO. I WORK TO HOUSE ADDITIONAL LOG.OR @ $1 00 TRUNK PERMIT NO. ROAD PERMIT N0. ALTER,OE PAIR O AL SYSTEM HOUSE @ $f 00 STATE ENCROACHMENT SEW _�sA PERMIT NO. Q P- I/w INDUSTRIAL WASTE APPROVAL CHARGES u OWNERS PERMIT 5 CONNECTION CHARGE FEE 1 AUTHORIZATION TOTAL FEE (F'-[? REIMBURSEMENT FEE n I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR-SSIGNATURE TO THE PUBLIC SEWER. ? SIGNED THIS-DAY DAY OF 19_ NEW HOUSE SEWER OWNER OR t't o CONNECT CT ADDITIONAL OWNERS AGENT J BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) �iJ�� /`,-• ANO/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ✓ �' r AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ YOf WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR y PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOSANGELESCOUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 AM THE, LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENT/IA/$. PROPE `JBACKFILL SEPTIC TANKS ❑ SIGNATURE J[�/J�) �1/� 7�Q, SEE PITIS) ❑ CESSPOOLS ❑ OF PERMITTEE �o`�_ � b" /Z!ALI.Q. SING-MROBERTA. W06D 1 ��,CKDy Y.Q. CASH SUPERVISING ENGINEER 1, WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 93-0002 DPW 3/67 qj insure, or a<Ertificate of Workers'Compensation Insurance, or 76A64D a Certified copy thereof (Sec. 3800, Lab C.) CE BOB APPLICATION FOR PERMIT Policy No. Company ®s �p�p p El 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' BURDINGe STATION Sj�J� ' DEPTH10 COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the MANHOLE REFERENCE PPER permit is for one hundred dollars ($100)or less.) LOCALITY .. a// Ods- O / LOWER NEAREST _ _ TYPE OF CONNECTION SIENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L. P. NO. permit is issued, I shall not employ any person in any manner -® so as to become subject to the Workers'Compensation Laws, B OWNER CO.IMP.NO. J08 NO. MAIL Date Applicont TRUNK PERMIT NO, ROAD PERMIT NO. ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of CITY lZe - AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. , DATE Exemption, you should become subject to the Workers' Compensation provisions of the Labor code, you must forthwith LEGAL P P Y DFSCRIPTI N -/LOT NO, HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT . . LICENSED CONTRACTORS DECLARATION NOOF BUNDS 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 _ a O Contractor DateDISTRICT NO. GROUP MAP PROCESSED BY O CITY TEL NO. BK PG Z ❑ I am exempt under Sec. of the L.A.Co. STATE LIC. �D v - O P LICENSE NO. CLASS o Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL U HOUSE SEWER CONNECTING TO DATE VALIDATION w B. 8 P. Code for the following reason PUBLIC SEWER ' 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 WORK TO HOUSE SEWER D / OVERFLOW SEEPAGE PIT,DRAINFIE D I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL.DRYWEU,MANHOLE Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE �r fSSi Its Code): SEWER OR DISPOSAL SYSTEM .LJ 2I,as owner of the property,or my employees with wages as ^i!:1.1 =a their sole compensation,will do the work and the structure -M37 c is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ `.,;, AUTHORIZATION _ _ T" "L' ❑ I,as owner of the property, am exclusively contracting with TOTAL FEE � licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I I�I til CL -- 7F, Business and Professions Code), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER, _ CONSTRUCTION LENDING AGENCY "��.' �'L - /•� I herebyaffirm that there is a construction lending agency SIGNED THIS DAY OF _ 19_ D s11..}^i- 9 g Y OWNER OR .I'fE114.T= _I it •for the performance Of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Nome i,/ V1.11) Lender's Lender's Address7 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 lows regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-me nt'oned grope ty.for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE