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HomeMy Public PortalAbout9028 EMPEROR AVE_Sewer__ DEPAKTMENT OF COUNTY ENGINEER E DISPOSAL \� DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER ADDRESBUILDINSG FOR APPLICANT TO FILL IN LOCALITY ADDRESS NEAREST CROSS ST: � G `' Z/I/Yvl�� m_ LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. c NEAREST ' , A 1 Cl c 6lq ~J CROSS ST. ff// RECEIVED BY Ready for Inspection DATE ISSU\ED,�/ I1_e V "T MAIL USE ZONEl OCCUPANCY I MAP ADDRESS BK PG CITY TEL.NO. CONTRACTOR CO.IMP. NO. ADDRESS ,� !OB NO. CITY � � TELAO. TRUNK PERMIT NO. ❑ STATE REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO. LEGAL STATE ENCROACHMENT DESCRIPTION LOT NO. PERMIT NO. BLOCK TRACT INDUSTRIAL WASTE APPROVAL SIZE OF LOT NO.OF BLDGS. NOW ON LOT CHARGES USE OF BUILDINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE PUBLIC SEWER @ $ 3.50 RECEIPT NO. I DATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING NO' I DATE BY _SEWER OR DISPOSAL SYSTEM 1.00 _ DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR --PITS AND/OR DRAINFIELD 2.00 STATION DEPTH CESSPOOL—D RYW ELL ss�� SPECIAL CONDITIONS ONLY 2.00 z ©O MANHOLE REFERENCE UPPER LOWER TYPE OF CONNECTION LENGTH FROM OWNERS I PERMIT $ I Y. CURB P.L. M.L.TO P.L. AUTHORIZATION 11 TOTAL FEE 3 .00 IHAVE 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........................................19...-... NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT------------.-.---------- - BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) ADDRESS--------------------------------------------------------------------------------------------- AND/ORDRAINFI.ELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL t/I RYWELL� 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 CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS SIGNATURE SEEP.PIT(S)[:] CESSPOOLS E] OF PERMITTEE• .....-- --------------------5. -= 76A642A' 663 7/53 rl TEMPLE CITY 76A642D `AP LI I N FOR PERMIT 6A64 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A, LAMBIE, County Engineer ADDRESS neror. Ave WILLIAM A. JENSEN, Sup't of Building_ LOCALITY Tem- le Cit FOR APPLI cROSSST. Rosemead Bl. LEGAL OWNER Hubner DESCRIPTION LOT NO. (�' BLOCK TRACT MAIL ADDRESS OF B GS. SIZE OF LOT OW ON LOT CITY L. NO USE OF BUILDINGS 2 Res, . 1 Gar. DISTRICT NO. GROUP MAP Il(z::'4 Al"-j-- LL[ PG CONTRACTOR square Deal Sewer Service ADDRESS 2933 Maxson Rd. CONNECTION DATA CITY 1 MonteTEL.NO. STATION DEPTH r REGISTRATION NO. 128870 .e ® STATE .` MANHOLE REFERENCE �' UPPER COUNTY NO. DESCRIPTION OF _WORK FEE 1 PUBLIC SEWER CONNECTING TO @ S 00 �0 TYPE OF CONNECTION--,A LENGTH FROM PITS AND/OR DRAINFIIELDSEPTIC TANK,SEEPAGE T OR @ 00 j Y. CURB P'c. TO P.L. OVERFLOW SEEPAGE PIT,DRAINFIELD >- EXTN..CESSPOOL.DRYWELL @ S .00 O_ HOUSE SEWER CONNECTING TO P.C.NO. O PRIVATE DISPOSAL SYSTEM @ S .00 CO.IMP. NO. JOB NO. CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. QL WORK TO HOUSE SEWER @ S1.00 SEWER OR PAIRO R A SYSTEM HOUSE @ S 00 STATE ENCROACHMENT 0 PERMIT NO. U 'S INDUSTRIAL LU WASTE APPROVAL N ��pppa� CHARGES z iu OvMER�S PERIL $ 2 00 CONNECTION CHARGE FEE A�TTYiORIZATION TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATV �g ECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED TrDAY OF 19. NEW HOUSE SEWERS OWNER OR CONNECT ADDITIONAL OWNERS AG N7s /,arc �� BUILDING OR WORK 77 SEPTIC TANK,SEEP.PIT(S) ADDRES AND/OR DRAINFIELD 1 HEREBY/ACKNOWL DGE THAT t HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTE14 1HEREBY 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 1 AM THE LEGAL OWNER THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ SIGNATURE SEEP.PIT(S ❑ CESSPOOLS 11OF PERMITTE �ALWATION ROBERT A. WOOD 11.0. K, n.o. CASH SUPERVISING MECHANICAL ENGINEER JUL 2 3 1 0 A 7.0 ONco WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6/89 I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or 76A8a2D PolcylNo.��sCompanec. 8y� 9 •evw� APPLICATION FOR PERMIT ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDINC'saAND SAFETY tment Date y23 Applicant �o�,n 5 7wvS �J FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' U BUILDINGy� Q �% STATION �� DEPTH COMPENSATION INSURANCE ADDRESS lJ D4 &A e—1 (This section need not be completed if the work involved by the MANHOLE REFERENCE permit is for one hundred dollars ($100) or less.) LOCALITY / IOWER NEAREST TYPE OF CONNECTIONLENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y CURB P L M L . P L permit is issued, 1 shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers' Compensation Lows. DESCRIPTION LOT NO, CO IMP NO JOB NO BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ASSESSOR Q AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE NOTICE TO APPLICANT: If, after making this Certificate of MAP BOOK O PAGE PARCEL&V®?,O:Z Exemption, you should become subject to the Workers' NO,OF BLDGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT , LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER r\�� PERMIT NO 9 (commencing with Section 7000) of Division 3 of the BUsi- MAIL CHARGES Hess and Professions Code, and my' license is in full force and ADDRESS effect. >y/� CITY TEL.NO. CONNECTION CHARGE FEE License Number �7 CO�VLIC.Class `� ��� REIMBURSEMENT FEE Contractor J Date CONTRACTOR 0 DISTRICT NO GROUP MAP PROCESSED BY ADDRESS Q�d BK PG ❑ I am exempt under Sec, of the L.A.Co. �/� �y� ��� Ilk 3 3 �ljp -,-3 / �� CITY ► \V I�.y v' TEL.NO. 0 O Plumbing Code and/or Sec. of the STATELIC. FINAL U LICENSE NO. s 3 I CLASS C--3 DATE _ VALIDATION Z B. 8 P. Code for the following reason No. DESCRIPTION OF WORK FEE L O HOUSE SEWER CONNECTING TO FINAL F— Date PUBLIC SEWER BY W SEPTIC TANK SEEPAGE PIT OR d Signature PITS AND OR DRAINFIELD rn OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING To ► Z PRIVATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR i=t Law for the followingreason Secton 7031.5, Buisness and Pro- WORK O HOUSE SEWER E s fessions Code): ( OVERFLOW SEEPAGE PIT ELL MANHOLE E?t-t•i u3 ) E%TN,CESSPOOL.DRVWEII, MANHOLE ALTER REPAIR OR ABANDON HOUSEEl I, as owner of the Pro property, or my employees with wages as ti ij et PJ SEWER OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure 1 T Ey�" is not intended or offered for sale (Section 7044, Business and Professions Code). ; 0 T ( 53 70 ❑ I, as owner of the property, am exclusively contracting with Permit $ {_ a: -C. licensed contractors to construct the project (Section 7044, OWNER'S " HEI,'3, e._ Business and Professions Code). AUTHORIZATION I TOTAL FEE7) j,;GE .�'q;_; CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '�� I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER _ for the performance of the work for which this permit Is _ •t„._. issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ I. iE 1-0l "i OWNER OR Ngo Lender's Name OWNERS AGENT 1 Arl i'o 10 Lender's Address 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 upon the above-men Toned property for inspection purposes. gnature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE