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Home My Public Portal About9144 EMPEROR AVE_Sewer__ 78A842D 5&E 86312 54 APPLICATION FOR PERMIT 1 DIVISION OF BUHMING AND SAFETY SEWER—SEWAGE DISPOSAL. Department of County Engineer County of Los Angeles BUILDING WM.J FOX, COUNTY ENGINEER ADDRESS CASSATT D GRIFFIN, SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST CROSS ST LEGAL DESCRIPTION LOT NO OWNER BLOCK TRACT J MAIL ADDRESS /9 NO OF BLDGS SIZE OF LOT y / ;S NOW ON LOT ` CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP g BK PG CONTRACTOR CALIF.St1Uf PONST GO. 5- L. - 't sa�E-R �vry-sr. ADDRESS A?1-evOGEGROVE CONNECTION DATA CITY �n��tTE'� tY E�1 O TEL N�R 1_6048 STATION �' { _ DEPTH trt — ❑ STATE f'J /f s' MANHOLE REFERENCE REGISTRATION NO ❑ COUNTY f UPPER AAAy4 148658 (STATE ) RTYPE OF CONNECTION LENGTH FROM NO DESCRIPTION OF WORK FEE rY— _C.URa_ P L M L TO P L HOUSE SEWER CONNECTING TO PUBLIC SEWER Q S 3 50 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 100 CONNECT ADDITIONAL BLDG OR CO IMP NO 115-61 JOB NO _ WORK TO HOUSE SEWER 1 00 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 SEPI IC TANK, SEEPAGE PIT OR _ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL CESSPOOL-DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 200 CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE B'D'fn' TRACTORHAVE T TOS CONNECTDATE ONTRTHEA ABOVE WDESCR BED EXITH THE ISTINGNAMED DWELLING APPROVALS DATE INSPECTOR SSIGNATURE TO THE PUBLIC E ER SIGNED TFII DAY OF 19 NEW HOUSE SEWER OWNER OR I CONNECT ADDITIONAL OWNERS AGENT _P_ W BUILDING OR WORK SEPTIC TANK, SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND 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 I hEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPE Y BACKFILL SEPTIC TANKS❑ p ,.* SEEP PIT(s) El CES SPOOLS 2td'�O SIGNATURE OF PERMITTEE , WILLIAM J FOX, COUNTY ENGINEER VALIDATION BY AC0 7 6 0 1 SEP 6 4 4.5 0 DEPUTY DEPUTY ,BT BY' _0 DEPUTY DEPUTY WORKERS' COMPENSATION DECLARATION I-hereby affirm that I have'', •zertificote of consent to self insdre, or Q certificate of Workers'Cgmpensatic n hsu nce, or 7sAsazD a cerlifie eof (Sec. 3800, 92-0002 DPW 6/88 Z ' N Company 1� APPLICATION FOR PERMIT ertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed witkthcounty building in pectin COUNTY OF LOS ANGELES BUILDING AND SAFETY dDate Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMM WORK S' BUILDIN — COMPENSATINCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY19 LOWER NEARE � I certify that in the performance of the work for which this CROSSSST. �s TYPE OF CONNECTION LENGTH FROM'V J+vITd Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any monner subject to the Workers'Compensation Laws. ^ P.C.NO. so as to become sub I P OWNER `- (�� - + CO.IMP.NO. !OB NO. MAILLA TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS 2 C s AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY llfc Al2A 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. s 7- CONTRACTOR -_ CONNECTION CHARGE FEE License Numb�er ( I LIC.Classt .� ADDRESS REIMBURSEMENT FEE Contractor /` ` J.b�` D,1@ / '`�1 e DISTRICT NO. GROUP MAP OCESS Y CITY TEL.NO. 5,16t /STATEL4 5 1 UC. K/r BK PG ❑ I am exempt under Sec. of The L.A.Co. LICENSE No. CLAss (••) Plumbing Code and/or Sec. of the NO. DERIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TOA.PUBLIC SEWER DATE VALIDATI N ./ B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY L) PRIVATE DISPOSAL SYSTEM % � Signature CONNECT ADDITIONAL BLDG.OR 0- WORK TO HOUSE SEWER OWNER-BUILDER DECLARATION Z OVERFLOW SEEPAGE PIT,DRAINFIELD — I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE ILI Law for the following reason (Secton 7031.5;BUisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ACCTA' ❑ I,as owner of the property,or my employees with wages as �� ^� = their sole compensation, will do the work and the structure °'"'1J is not intended or offered for sale (Section 7044, Business 1 ITEMS and Professions Code). OWNERS Permit $ ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE 6 TOTAL 4 .50 licensed contractors to construct the project (Section 7044, I HAVE AT THWVECRIBED CT WITH THE HEREIN NAMED CONTRACTOR TO CHECK r Business and Professions Code). CONNECT THE ISTING DWELLING TO THE LIC SEWER. C HECK 34n591 CONSTRUCTION LENDING AGENCY {_�� EI hereby affirm that there is a construction lending agency SIGNED THISDAY OF 19for the performance of the work for which this permit is OWNER Aissued (Sec. 3097, Civ. C.). OWNERS AGEN � , Lender's Name ADDREss �I—(� l � �1/19/911Lender's Address 8.+3211:1-31 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 law re ulating Plumbing and Sewers, and hereby authorize re es tatives of this County to enter upo he above-mentio d p perty for inspection purposes �- 1vitT Si ature of Permittlbe Dote SEE REVERSE FOR EXPLANATORY LANGUAGE