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Home My Public Portal About5222 DOREEN AVE_Sewer__ Dr.PARTMF,NT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER DUII /C ADDRLDESSNG FOR APPLIC T TO FILL IN LOCALITY BUILDING !y n� , NEAREST ' \ �J �- ADD. ESS ' llic�r CROSSST. LOCALITY ( DISTRICT I� SERIAL N0. PERMIT NO. C NEAREST 5 _ 3 V¢'J S CROSS ST ,s no YIw Ready for Inspection DATEISSUED OWNER MAIL USE ZONE OCCUPANCY BK MAP PB ADDRESS CITY TEL NO. X744 — / hh L T D CO NTRACTO RA �� - �{)� CO.IMP.NO. ADDRESSn - ,I /- �Q. (N JOB.NO. CITYui� TEL.NO /,-I?,(Y TRUNK PERMIT NO.ATE / �/✓C/��- STO2 (p 9•,y 6 tJ { REGISTRATION N0. 13- OMMTY ROAD PERMIT NO. LEGAL STATE ENCROACHMENT DESCRIPTION LOT NO. PERMIT NO. Z BLOC(( /O TRACT / fr� vO :NDUSTRIAL APPROVAL SIZE OF LOT NO.OFBLDOS. 01 SIZE S ''ww NOW ON LOT O�'� BUILDINGS �/r ,y"�[. �,n/��.7�A1JL(.USE OF CONNECTION CHARGE FEE NO. DES RIPTION OF WORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ = 3.50 Lf O RECEIPT N0. GATE' By HOUSE SEWER CONNECTING TO / PRIVATE DISPOSAL SYSTEM 1.00 , CONNECT ADDITIONAL BLDG.OR EXCEPTION RPORDED WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING NO. I DRL; BY SEWER OR DISPOSAL SYSTEM 1.00 l DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR ^ -;L. / PITS AND/OR D RAINFIE LD. 2A0 STATION L i-/n DEPTH CESSPOOL—ORYWELL • SPECIAL CONDITIONS ONLY 2.00 ` / -� NHO ERREFERENCE TY//PE OF CONN�ON LENGTH FROM1f 3a / OWNERS PERMIT S 1 00 cuae 11 A. M.L.TO P.L. J AUTHORIZATION TOTAL FEE 5 b 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS._._ _... DAY OF...._ - � NEW HOUSE SEWER OWNER OR �� -y CONNECT ADDITIONAL _._...__.��__. ...... ..__.._.. .._.__.. _._.... BUILDING OR WORK OWNERS AGENT. SEPTIC TANK:SEEP.PIT(S) ADDRESS.._..........._......__...._........._.. ......_......_.._......_....._..._. AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL O DRYWELL CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY THAT I AMAND%R LIICENSED CERTIFY AS REQUIRED BY RE EANGE ES(STERED COUNTY DISCONNECT PLUG AND AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS SIGNATURE t - yA�l eek SEEP.PIT(S)Q CESSPOOLSVI OF PERMITTEE.y=_:.'.^"T:..Nr ..`�'!.....c+�....'.. 76AG42A 663 7/�3 � �� WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of-consent to self' ' insure, or a certificate of Workers'Compensation Insurance, or 76ANRD a certified copy thereof (Sec.-3800'Lob C.)T RR-MV DPW 6188 APPLICATION FOR PERMIT Policy No. Compony ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL n ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Illi department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �7 /f // STATION DEPTH COMPENSATION INSURANCE ADDRESS y2 /d t _ U ' (This section need not be Completed if the work involved by the r1�C G MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY TYPE OF CONNECTION LOWER NEAREST M.L.10 FROM I certify that in the performance of the work for which this CROSS sr. � Y. CWB P.L. M.L.tO P.I. permit is issued, I shall not employ any person in any manner _ P.c.NO1 so as to become subject to the Workers N Compensation Laws. OWNER ��L L `�� rU /L.1� CO.IMP.NO. JOB O. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Dote Applicant ADDRESS _ 1-1 r 0 E� '4111 NOTICE TO APPLICANT: If, after making this Certificate Of CITY AFFIDAVIT WAIVER EASEMENT RECORD.INSTIL.NO. DATE Exemption, you should become subject to the Workers' LE GiTEL.No. y LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT NO OF PERMIT NO. OT I hereby affirm that I am licensed under provisions of Chapter USE Of 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS 5 rC7 CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR V CONNECTION CHARGE FEE ESS License Number Llc.Class ADDRD S 4. L REIMBURSEMENT FEE Contractor Date L( �,�L PBY GROUP MAP PROCESS BY CITY G�� LEL NO. BK PG ❑ I am exempt under Sec. of the L.A.Co. LICEN CL d P STATE E NO. CLASS Q Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE U HOUSE SEWER CONNECTING TO VALDATI NB. 8 P. Code for the following reason PUBLIC SEWER 0SEPTIC TANK.SEEPAGE PIT OR _Date PITS AND/OR DRAINFIEID WHOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OROWNER-BUILDER DECLARATION WORK TO HOUSESEWER I z OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractors License EXTN.,CESSPOOL DRYWELL,MANHOLE 1� Law for the following reason (Secton 7031.$, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE d- fessions Code): SEWER OR DISPOSAL SYSTEM A ACCT. < ❑ I,as owner of the property,or my employees with wages as .�' their sole compensation, will do the work and the structure 3,707 .Q is not intended or offered for sale (Section 7044, Business Permit $ 1 ITEMS Professions Code). OWNER'S ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATIONJ TOTAL FEE TOTAL 34 - 50 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH iNE HEREIN NAMED ONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK 34.50 CONSTRUCTION LENDING AGENCY CHANGE .011I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF IY/y for the performance of the work for which this permit is OWNER OR OWNERS AGENT 01300-00131 'L ''L,=I�j{(} ( �'L Lenge (SCC. 3097, Civ. C.J. ADDRESS VI3VUVi V/21�90 Lender's Nome Lender's Address 2.506 1 AN 9:36 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 above-mentioned property for inspection /purposes. Pa 1 nature of PermiNe°ed�A�� SEE REVERSE FOR EXPLANATORY LANGUAGE