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Home My Public Portal About9129 EMPEROR AVE_Sewer__ D S E-663 3.55 APPLICATION•AFOR PERMIT S @ E-6 DIVISION OF BUILDING ND SAFETY SEWER-SEWAGE DISPOSAL — Department of County Engineer County of Los AngelesBUILDING WM.J. FOX. COUNTY ENGINEER ADDRESS @ CASSATT D. GRIFFIN, SUPT OF SUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST LEGAL DESCRIPTION LOT NO. OWNER BLOCK TRACTQ MAIL ADDRESS SIZE OF LOT � OF BLDGS. /. � _ - /J "SOW ON LOT {-" CITY TEL. NO. USE OF __BUILDINGS ' DISTRICT ND. GROUP MAP BK PG CONTRACTOR S .4-a,,o%`^� ` L/ ADDRESSj 1 It S i� CONNECTION DATA CITY a TEL. NO. �►tJ, 6t1l6G STATION v - I Y" DEPTH W /p ❑ STATE MANHOLE REFERENCE �� UPrLMi REGISTRATION NO. / ❑ COUNTY ✓ ' Imo'" LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO LENGTH FROM PUBLIC SEWER @ $ 3.501 Y. CURB P.L. M.L. TO_P. -.1-L. '.✓ HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 ✓f CONNECT ADDITIONAL BLDG. OR ` P. C. N0. WORK TO HOUSE SEWER - I.00 CO. IMP. NO. s% �T JOB NO. ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD 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-DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 /�CH.RG CONNECTION CHARGE FEE OWNER'S PERMIT 1 00 AUTHORIZATION I TOTAL FEE I ✓ / REIMBURSEMENT FEE 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT T E ABOVE DEWR EXISTING DWELLING APPROVALS DATE INSPECTO S SIGNATURE TO THE'PUBLIC SEWER _ SIGNED THIS] DAY OF 1 NEW HOUSE SEWER (� f11✓h �I Rsa e;i OWNER OR !1 t_ ,i CONNECT ADDITIONAL. J 11 ✓U"i1/uR' �( OWNERS PCrmy ddd"'YYY /- BUILDING OR WORK SEPTIC TANK, SEEP. PIT(S) ADDRESS R AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION CESSPOOL EIDRYWELL(IAND 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 1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT I AM THE LEGAL OWNER'OF THE ABOVE ABANDON HOUSE SEWER. .fes DESCRIBED RESIDENTIAL,PROPERTY. BACKFILL SEPTIC TANKS❑ tt SEEP. PIT(S) ❑ .CESSPOOLS SIGNATURE OF PERMITTEE _ WILLIAM J. FOX.COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLSG. INSPECTOR 0 9 4 u SEP 19 4- k ;4.5 0 � WORKERS'COMPENSATION DECLARATION,, 'I hereby a4firm thdt`1 have a certificote-of-consdnt tp self insure, or a certificate of Workers'Compdnsdtion l6surbnce, Or 76A642D a certified-copy thopreof (Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy N"o. Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. LI Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTICV FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or.less.) LOCALITY LOWER that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM I certify p CROSS ST. Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. P. B NO. I P OWNER � CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after makin this Certificate Of IF AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT 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 •// CONNECTION CHARGE FEE License Number LIC.Class ADDRESS /, / REIMBURSEMENT FEE Contractor , fe �� ?� CITY Vry TEL.NO. �iJ U ? DISTRICT NO. GROUP MAP PG PROCE 0 BY ❑ I am exe t under Sec. of the L.A.Co. STATE _ uc. �O� �K J� P LICENSE NO. CLASS ` 0 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL eC•1 HOUSE SEWER CONNECTING TO DATE VALIDATI N g —3,..Gf B. 8 P. Code for the following reason PUBLIC SEWER Q .� SEPTIC TANK,SEEPAGE PIT OR FINAL I_Date PITS AND/OR DRAINFIELD n HOUSE SEWER CONNECTING TO BY /:/ 0 PRIVATE DISPOSAL SYSTEM /.%C- Ld Signature 1 CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION I WORK TO HOUSE SEWER ® z OVERFLOW SEEPAGE PIT,DRAINFIELD — I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 1D Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE r. s fessions Code): SE ER OR DISPOSAL SYSTEM A4�f aQ ❑ I,as owner of the property,or my employees with wages as .Pf f-tl 33073}j I their sole compensation, will do the work and the structure a n is not intended or offered for sale (Section 7044, Business 1 ITEMS and Professions Code). OWNER'S Permit $ ❑ I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE TOTAL 27 . 00 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO CHECK Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ® CHANGE .00 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 DOOR-GDD1 2/28/90 Lender's Name Oj 1v*G 1 AN 9:47 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 upon the above menti ned property for inspection purposes. Si nature f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE