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Home My Public Portal About4572 ELLIS LN_Sewer__ ;•76A64`°LD ® IiATI Op . O PERMIT .RMIT . . 5,&E-663 12-54 DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D e S POSH L Department of County Engineer County of Los Angeles t7N WM.J. FOX, COUNTY ENGINEER CASSATT-D. GRIFFIN, SUPT OF BUILDING 01 FOR APPLICANT TO FILL IN LEGAL Y� _DESCRIPTION LOT NO. OWNER BLOCK TRACT - MAIL ADDRESS NO. OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. USE OF - BUILDINGS AT� 1, DISTRICT NO. GROUP MAP PG CONTRACTOR M o C o No.1.U.1.V' ham Co. of BK ADDRESS 593/3 N. Cloverly Ave o a CONNECTION DATA CITYTemple. City yy TEL. NO: Xi-3-2311 STATION DEPTH MA REFEREN CE r STATE NHOLE REGISTRATION NO. 147012 ❑ COUNTY _ UPPER - '- LOWER TY CONNECTION LENGTH FROM NO. DESCRIPTION OF WORK FEE Y. CURB P.L. M.L. TO Pbb.L. s HOUSE SEWER CONNECTING TO P ✓• il- / PUBLIC.SEWER @ $. 3".50all TTTT— ,HOUSE SEWER CONNECTING TO `, ��,`n� - �r PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG. OR - - CO. IMP. NO. -dOB,NO. �. WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING - �' SEWER OR DISPOSAL SYSTEM 1-00 TRUNK PERMIT N0. CAD PERMIT NO. DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT _ AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO. SEPTIC TANK, SEEPAGE PIT OR _ PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL CESSPOOL- DRYM'ELL WASTE APPROVAL - SPECIAL CONDITIONS ONLY 2.00 CHARGES CONNECTION CHARGE FEE OWIVERIS PERMIT i 00 .AUTHORIZATION TOTAL FEE REIMBURSEMENT FES/ "/. 1 HAVE THIS DATE CONTRACTED WITH THE`HEREIN NA6 ED CON- - APP HAVE TO CONNECT�Up ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR•S•SIGN'ATURE J TO THE PUBLIC SEW RR7S5/7e• SIGNED THIS—'•UAY OF 1 NEW HOUSE SEWER OW N•ER OR - Lt CONNECT ADDITIONAL OWNERS AGENT r.�GT — UII. IN.Ci;Q,jp'Ra'" / TICTANK,.SEEP, PIT(S) ' ' ADDRESS D/OR DRAINFIELD 1 HEREBY ACKNOWLEDG THAT 1 HAVE RE D THI APPLICATION SSPOOL Da) LL AND-STATE THAT THE,ABOVE IS CORRECT AND AGREE TO COMPLY t� -T'+��!. " ? WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING - TER 3 ]Id �5EryaR flR�'•; L� .y �-� PLU MEING AND SEWERS. S AG F,,t I 'f.?.i Tg 1 ui.•,'• I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR D, CONNECT PLUG AND LICENSED-AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA ,OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE A NDON.HOUSE SEWER ' D SC IBED ESD NJIAL PROPERTY/•t .p —TI o , 10, in ham Co 0 o O o Cal. BACKFILL SEPTIC TANKS. f� Val o S .�a=t�T 8'''`t�55P'OU1S❑ f `- 4/ -S[OF PER METTEE � ✓.' �4 WILLIAM J. FOX, COUNTY ENGINEER VALIDATION 6 1, 3. 2� JUL 2 9 .3 4 1 .2 5 � ifl��,6 1 � .3 r JtJL 2 9 4 4.50 �' Y BY _ DEPUTY DEPUTY BY BY ®. - DEPUTY - DEPUTY WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) APPLICATION FOR PERMIT C I hereby affiim that I have a certificate of consent to self SEWER-SEWAGE ®I S P®SA L insure, r a certificate of Workers'Compensation Insurance,or a cert' ied copy thereof(SecLab. C COUNTY OF LOS ANGELES BUI LDING AND SAFETY Poli No: Com M-k1,-i,S2 J' S�°�� FOR APPLICANT TO-FILL IN CONNECTION DATA rtified copy Is hereby furnishe BUILDING /! ��f1 STATION F.3 DEPTH ADDRESS 6�� / v Certified copy is filed with the county building inspect' n �j ccs LOCALITY C� MANHOLE REFERENCE { O L Datk LApplicant NEAREST TYPE OF CONNECTION� LENGTH FRO CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. CURB lP L.) M.L. TO P.L. COMPENSATION INSURANCE P.C. NO. OWNER MAIL ` CO. IMP. NO. JOB NO. // (This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIA NO.6 f 0 by the permit is for one hundred dollus ($100) or less.) U AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE C ITV TEL. NO. I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ an person in any manner DESCRIPTION LOT NO. O P P Y P HWY. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. U BLOCK TRACT STATE ENCROACHMENT cu- Date— Date Applicant NO. OF BLDGS. PERMIT NO. Oma// a SIZE OF LOT NOW ON LOT Cn NOTICE TO APPLICANT: If, after making this Certificate of Z Exem tion, ou shouBUILDINGS CHARGES ld become subject to the Workers' USE OF P r y Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked. LICENSED CONTRACTORS DECLARATION ADDRESS '1 'I � j� R.E IM BURSEM ENT FEE I hereby affirm that I am licensed under provisions of Chapter ,CITY NO. PG DISTRICT NO. GROUP MAP PROCE EDBY L.. BK 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and STATE LIG LICENSE NO. • CLASS effect. /` '� NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL „mom � � � VALIDATION License Number Li4. lass,,�-- PUBLICSEWER DATE�7� SEPTIC TANK,SEEPAGE PIT ORContractor ��' Dr/^ � PITS AND/OR GRAINFIELD ry FINAL C6 HOUSE SEWER CONNECTING TO ' O BY PRIVATE DISPOSAL SYSTEM - I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR \ licensed architect or a registered professional engineer I WORK TO HOUSE SEWER h acting in my professional capacity (Section 7051, BUS- OVERFLOW SEEPAGE PIT,DRAINFIELD / iness and Professions Code). ALTER, CESSPOOL, O ABANDDRYWEON MANHOLE ALTER, REP S1 OR ABANDON HOUSE SEWER DIS SAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION z 2 G,0,6I_ A I.hereby affirm that I am exempt from the Contractor's OWNER'S Permit s S'1J License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE j :$€`O`o o,o 1•0. ness and Professions Code): HAVE AT THIS GATE A N A T WI H H HEREIN NAM D N- 2 O IO 1 7.50. TRACTOR TO CONNECT T E ABO E D C D EXISTING D INC 1, as owner of the property, will do ttie work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS Ay Irv/ o ono 1 17 .5 0 Fu 7044, Business and Professions Code). OWNER OR OWNERS AGENT 777 CONSTRUCTION LENDING AGENCY 1 ADDRESS (2.2 1.7'8 1. I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). Lender's Name Lender's Address I certify that have read this a catlo a tate that the above infor on is correct. I ree to o pl ith all County ordinance a State laws gula um g , d Sewers, and her y t�lorize repre entativ h' C my to enter upon ntioned e fo ec ose . SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Dat91