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Home My Public Portal About4908 DOREEN AVE_Sewer__ L, S420 E-6D S& 1195 APPLICATION FOR PERMIT 1 5& DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL DepDztment of County Engineer County of Los Angeles BUILDING D fj. ./ ^��Q/� ,.—� . I A . ADDRESS i A /� /y A)A JOHN A. LAMBIE. COUNTY ENGINEER —I ® CASSATT O. GRIFFIN, SUPT OF BUILDING - LOCALITY FOR APPLICANT TO FILL IN NEAREST. /�,AJa.✓ 4....s a 2r/' LEGAL S DESCRIPTION LOT�AO. 7 OWNER ��/C u S MAIL BLOCK TRACT �r .7 G B"T ADDRESS �j .1��✓. - SIZE OF LOT �'r 04 NOW ON"LOTS f�- CITY - TEL. NO. USE OF DISTRICT NL I GROUP MAP BUILDINGS `T` r 3 CONTRACTOR 1 P47' t� 4— r S v y L V ADDRESS L Q•L�� .^(d jo �! �, CONNECTION DATA T STATION ,� DEPTH clry r TEL. No. Ak T O A77 L o A MANHOLE REFERENCE UPPER REGISTRATION NO. / L, q .L 4 (�[] COUNTY •_ N0. DESCRIPTION OF WORKFEE - TYPE O]F ON TION LENGTH FROM o HOUSE SEWER CONNECTING TO vv. CURB � -,W*- M.L. TO P.L. PUBLIC SEWER @ $3.50 VV SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT. DRAINFIELD . N EXTN.,CESSPOOL.DRYWELL,MANHOLE @ $2.00 CO. IMP. NO. P ' JOBC.,o0. HOUSE SEWER CONNECTING TO 3.2.5' <1// PRIVATE DISPOSAL SYSTEM a $].Do TRUNK PERMIT NO. ROAD PERMIT NO.. /��9y CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT WORK TO HOUSE SEWER @, b 1.00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM n $ 1.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE - OWNER'S PERMIT g 1 00 AUTHORIZATION ITOTAL FEE :Yjso REIMBURSEMENT"FEE i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWE, NEW HOUSE SEWER SIGNED THIS -• DAY F 19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK ' OWNERS AGENT SEPTIC TANK.SEEP, PIT(S) ADDRESS O . . AND/OR DRAINFIELD - I HEREBY ACKNOWLEDGE THAT i HAVE READ THI PPLI CATION CESSPOOLE1 DRYWELL E AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I"AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RES[DENT] LPROPERTY. SEEPBACK, PITS)PTI ceANNKS El pp I' SIGNATURE /q� Pn OF PERMITTEE •� •� veq JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR CH. N.O. [CSS 4 � 5 0 to 2 2 6 2;9 aA%27 WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of conse'ht to self insure, or a certificate of Workers'Compensation Insurance, or Tdiaa3o• IL a certified copy thereof (Sec. 3800, Lab C.) CE 8081 REV.1/831 APPLICATIONPolicy No. company . FOR PERpApSp !1 El - SEWAGE DISPOSAL II Certified copy is hereby furnished. .. ❑ 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 STATION DEPTH COMPENSATION INSURANCE ADDRESS Q (This section need not he completed if the work involved by the f MaNHOLE REFERENCE I.owER permit is for one hundred dollars ($100)or less.) - LOCALITY I certifythat in the NEAREST TYPE OF CONNECTION LENGTHFROM performance of the work for which this CROSS ST. Y. CURB P.L M.L.TO P.L. permitisissued, I shall not employ any person in any manner _ pc NO, so as to become subject the Workers Compensation WE. OWNER CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date plicont ADDRESS NOTICE TO APPLICANT: If, after making this Certific a of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Ing CITY TEL NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you. must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION SIZE OF LOT NNO.OFOWON LOT LOT ' PERMIT No. I hereby affirm."That I am licensed under provisions of Chapter " USE of 9 (commencing with Section 7000) of Division 3 of the'Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR 0 CONNECTION CHARGE FEE License 10/O LiC.Class " ADDRESS DISTRICT NREIMBURSEMENT FEE d PG Contractor ' Date " /, O. GROUP BK MAP PRSSED BY S CITY iM1. te I EL.NO. IC ❑ I am exempt under Sec. of the L.A.Co. STATE CLLICX �� P O P IICEN$E NO. O CLA55 ✓ (/O Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL V HOUSE SEWER CONNECTING TO DATE �✓ ��D _ VALIDATION W6 B. 8 P. Code for the following reason PUBLIC sewER Q SEPTIC TANK,SEEPAGE PIT OR 1 N FINAL PITS AND/OR DRAINFIELD Z Dote HOUSE SEWER CONNECTING TO BY �l PRIVATE DISPOSAL SYSTEM Signature CONNECT.ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License ExTN..CESSPOOL,DRYWELL.MANHOLE p 'I Law for the following reason (Sector 7031.5, BUiSness and Pro- ALTER,REPAIR OR ABANDON HOUSE q6 1 fessions Cade): SEWER OR DISPOSAL SYSTEM MI fr � L] 1,as owner of the property,or my employees with wages as �Q;o io•215 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business o�o'e 21.5 Q_ r� Permif and Professions Code). OWNER'S 8 (� p o8,1 '6-84 ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE - ' licensed contractors to construct the project (Section 7044, I 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 i 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 - up n the above-menti ned p pert for inspection purposes. , Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE