HomeMy Public PortalAbout4515 ELLIS LN_Sewer__ WORKERS'COMPENSATION DECLARATION 808 (2-80)D
CE APPLICATION FOR PERMIT
CE 808 C `QUI
I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.) A COUNTY OF LOS ANGELES �.� BUILDING AND SAFETY
Policy No. om any ����� �4, '-++ x
S7- _ FOR APPLICANT TO FILL IN,5:-L- 7 CONNECTION DATA
Certified copy is hereby furnished.
BUILDING A ���.�// n_ _ STATION DEPTH
❑ Certified copy is filed withZ��
building ADDRESS (( C�Cly / t
p g inspection UPPER
department. �- / MANHOLE REFERENCE ^�
P LOCALITY I=�y� / [,% oC [Date d-l'5-6' -Applicant NEAREST TYPE OF CONNECTION LENGTH FROM
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. , ct_L ZLL, r. CURB P.L. M.L. TO P,L.
COMPENSATION INSURANCE { / -<���fG� ,_/ / P.C. NO.
OWNER /� I �r�-Ci CO. IMP. NO. JOB NO.
MAIL - d
(This section need not be completed if the work involved ADDRESS �Z� S /� ZL TRUNK PERMIT NO. ROAD PERMIT NO.
^%
by the permit is for one hundred dollars ($100) pr less.) c1 / �j AFFIDAVIT WAIVER EASEMENT RECORD, INSTR,NO] DATE
C IT S�.� C4)4b 110- TEL. NO.
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I certify that in 'the performance of the work for which this LEGALcr
4 31:;
permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. 0 J 6 " HWY. OR ST. WIDENING
so as to become subject to the Workers' Compensation Laws. f 0
STATE ENCROACHMENT TRACT > 7�J3
U
Date Applicant NO. OF BLDGS. PERMIT NO. W
NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT
Exemption, you should become subject to the Workers' USE OF CHARGES Z
Compensation provisions of the Labor Code, you must forth- BUILDINGS _
with comply with such provisions or this permit shall be CONTRACTOR � c�.•C `�>� CONNECTION CHARGE FEE
deemed revoked. /
REIMBURSEMENT FEE
LICENSED CONTRACTORS DECLARATION ADDRESS �(i Ojij/� ct! (L{r
I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED BY
9 (commencing with Section 7000) of Division 3 of the Busi- clrr J ! �[ TEL. No:ZLIC. //7 F `BK PG
ness and Professions Code, and my license is in full force and STATE
LICENSE No. (ci �N � CLASS � ✓/ �� "� ✓ 02
effect. NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO FINAL ' /+ VALIDATION
License Number TL�
Lie.Class t PUBuc SEWER DATE
SEPTIC TANK,SEEPAGE PIT OR
�1 ^x/ PITS AND/OR DRAINFIELD
Contractor d, ��+� Date /��3—V FINAL
HOUSE SEWER CONNECTING TO 6Y
❑ PRIVATE DISPOSAL SYSTEM
I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR
licensed architect or a registered professional engineer WORK TO HOUSE SEWER
acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD �t
IReSS and PLOfe$SIORS Code). EXTN.,CESSPOOL,DRlWELL.MANHOLE ///��✓✓✓JJ III///���
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM / 'f
Lie.or Reg.No. Date Oi
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNERS Permit S
License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE Ll
/ ;21 9S'4 A
ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED E—STING DWELLING # O r0:0 O'1, 0!
1, as owner of the property, will do the work and the TO THE PUBLIC SEWER.
structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19DID 1 O O
7044,Business and Professions Code). OWNER OR
OWNERS AGENT Q
CONSTRUCTION LENDING AGENCY ADDRESS
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is 1, 1 3-8;1
issued (Sec. 3097,Civ.C.).
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 1
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon I Vie above-mentioned property for inspection purposes.
iC�`�;,t] Z- �� SEE REVERSE FOR EXPLANATORY LANGUAGE
��i /0 �-
Signature of Permittee Date
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 1201240008
.BUILDING AND SAFETY / LAND DEVELOPMENT' TEMPLE CITY CA 91780 _
PHONE: (626) 285-0488 EXT:
ILEGAL ID: ISEWER / SEPTIC.: SEWER - BUILDING ADDRESS:
ITR: 37582 UN: 5 IEXIST OCC GRP: 4515 ELLIS LN
I IBLDGS. NOW ON LOT: TEMP CA 917804249 I
(ASSESSOR INFORMATION-NUMBER: (CONNECTION TYPE: - NEAREST CROSS STREET:
18592-001-051 IORIGINATION: THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY, CI
(LENGTH ML TO PL: STATION: DEPTH;t. —.
(TENANT: (MANHOLE REFERENCE: UPPER/LOWER: +(ISSUED ON: PROCESSED BY:
I 101/24/12 SR 1
ICOUNTY IMPROVEMENT NUMBER: 1 I
(OWNER: TEL. NO: IPLAN CHECK NUMBER: IFINAL DATE FINAL BY: CODE: I
CHENG, JUDY (626) 258-8352- IJOB NUMBER: Ii
14515 ELLIS LN ITRUNK PERMIT NUMBER: /I V
ITEMP 917804249 IROAD PERMIT NUMBER: - 1DtSCfZfPTION OF WORK I
I IAFFADAVIT: NO 11P;STALL SEWER CLEAN OUT I
I 1WAIVER: NO I I
(APPLICANT: TEL. NO: (EASEMENT: NO
IRESCUE ROOTER (626) 858-9284- I I
I IRECORD INSTRUMENT NBR: RECORD DATE: - ISPECIAL CONDITIONS:
IHIGHWAY/STREET WIDENING:
STATE ENCROACHMENT PERMIT NUMBER: D\
ICONTRACTOR: TEL. NO: 1 FEES PAID (APPROVALS w� DATE `(INSPECTOR SIGNATURE I
IRESCUE ROOTER (626) 858-9284- L-2
1475 E ARROW HWY LIC. NO IFEE DESCRIPTION: QUANTITY:. UOM: AMOUNT: INEW HOUSE SEWER
IAZUSA CA 91702 765155 C42 *1 - 1-
101 PERMIT ISSUANCE FEE 27.80 CONNECT ADDITIONAL
115 ALT/REP HOUSE SEWER 1.00 EAC 30.40 IBUILDING OR WORK
1.ARCHITECT OR ENGINEER: . TEL. NO: I TOTAL FEES 58.20 1
- 1 ISEPTIC TANK, SEEPAGE PITI I I
LIC. NO: 1ANll/OR DRAIN FIELD I
1, IDRYWELL
I I I
SEWER MAP BOOK: PAGE: 1ALTER, REPAIR, SEWER OR. 1 II
I ISElWAGE DISPOSAL SYSTEM
) I I I
IDISCONNECT PLUG AND I I
IAB?NDON HOUSE SEWER
I I
19ACKFILL SEPTIC TANKS
ISEEP. PIT _ CESSPOOL
_ I s. CRAYWATER SYSTEM I
I I I I I I
I I I I I I
I I I I i I
I I I I I I
I* ADDITIONAL DATA ON FILE 1
I I I I I I
I IREPORT ID: DPR266 ROUTE TO BS0508 1
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