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HomeMy Public PortalAbout5019 ENCINITA AVE_Sewer__ Q,xo� 76A 642D-CIoE808 A-7/76 APPLICATION FOR PERMIT SEWER—SEWAGE DISPOSAL COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION DISTRICT NO. GROUP MAP PRO SSED BY BU'LFOR APPLICANT TO FILL IN �` BK PG ADDRENG a. SS '�' �I• e S ©� J(i(�Y'L(,yL, "y'pyI LOCALITY CONNECTION DAT NEAREST STATION DEPTH CROSS ST. MANHOLE REFERENCE UPPER LOWER F OWNER �N �SP LC/ TYPE OF CONNECTION LENGTH FROM MAIL S Y. CURB P.L. M.L.TO P.L. AD DRESS�O/ �`` `, 4 P.C.NO, CITY L. NO. CO. IMP. NO. JOB NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. '� L•/ --7"-/ � �" AFFIDAVIT w�nu CASEMENT RECORD. INSTR.NO. DATE BLOCK TRACT NO. OF BLDG 5' SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF STATE ENCROACHMENT BUILDINGS d/�//�[/ /J�p A//'.T' /J',7 PERMIT NO. INDUSTRIAL CONTRACTOR `�P ffjj1V 6 C1 W/W�/ W WASTE APPROVAL ADDRESS /-b-3 Wr 161yy 4 �'`� Q^J CHARGES CITY �a TEL. N ZI3�—rS2=-2?a' CONNECTION CHARGE FEE STATE r LIC 'f REIMBURSEMENT FEE LICENSE NO 0G/ J Z CLASS �� G... No. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR.SSIGNATURE �y HOUSE SEWER CSO .PARI I R SEPTIC TANK.S PAGE PIT OR PITS AND/OR DRAINFIELD @ CONNECT ADDITIONAL �� o HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM SEPTIC TANK.SEEP.PIT(S) CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL Cl DRYWELL ❑ EXTN.,CESSPOOL.DRYWELL.MANHOLE �/p� R ABANDON HOUSE ALTER,REPAIR,SEWER OR cam- DISPOSAL SYSTEM @ D SEWAGE DISPOSAL SYSTEM .I O DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ❑ CESSPOOLS ❑ OWNER'S Issuance Fee $ —v ICATION AUTHORIZATION TOTAL FEE L> AND H STATE THAT EREBY ACKNOWLEDGE EABOVE THAT CORRECT ANON A I HAVE READ THIS COMPLY WITH ALL COUNTY. ORDINANCES AND STATULATING I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. PLUMBING AND SEWERS. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY AND/ORTO THE PUBLIC SE LICENSED AS REQUIRED BY LOS ANGLES COTATE OFSIGNED THIS - OF 1 e CALIFORNIA OR THAT 1 AM T E LEGAL OWNEND TOOWNER OR S C RESIDE IN. THE ABOV DE IBE. SI N +OWNERS AGE SIGNATURE OF PERMITTEE VALIDAT 1 5 8 r:Itm 23 1 0 2 4.0 0 a +l� 76A 642D-CE808 A-7/76 APPLICATION OR PER, -SEWER-SEWAGE DISPOSA r COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN DISTRICT NO. GROUP I BK MAP PS OCESSED BY [cITY UILDING ��X// DDRESS _ ' � F f� (ill �• V.N� / 1 —/�/V OCALITY �� � �f ` CONNECTION DATA EAREST STATION DEPTH ROSS ST. �./CCCJJJ MANHOLE REFERENCE / it i/� i� Q/ -- �9 LOWER TYPE OF CONNECTI LENGTH FROM AIL Y. CURB .L. M.L.TO P.L. DDRESQ - P.C.NO. CO.IMP. NO. JOB NO. _ TEL. NO. LEGAL TRUNK PERMIT NO. ROAD PE lT DESCRIPTION LOT NO. i AFFIDAVIT WAIVER I EAS[MEHT RECORD.INSTR.NO. &ATE 11 BLOCK TRACT NO. OF BLD GS. SIZE OF LOT NOW ON LOT HWY. OR ST.WIDENING USE D LDINGS BUISTATE ENCROACHMENT PERMIT NO. INDUSTRIAL CONTRACTOR N WASTE APPROVAL l ADDRESS ! CHARGES 0 CONNECTION CHARGE FEE 19 CITY TEL. NO. ,. STATE LIC REIMBURSEMENT FEE LICENSE NO. CLASS No. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE La / HOUSE SEWER CONNECTING TO PUBLIC SEWER @ (/ �✓ `� (� SEPTIC FANK.SEEPAGE PIT OR NEW HOUSE SEWER PITS AND/OR DRAINFIELD @. CONNECT ADDITIONAL o HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM SEPTIC TANK.SEEP.PIT(S) CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD WORK TO HOUSE SEWER 0 OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL ❑ E XTN..CESSPOOL.D RYWELL,MANHOLE ALTER.REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS ❑ p+� 7 SEEP.PIT(S) D CESSPOOLS �4+ Q OWNER'S Issuance Fee $ AUTHORIZATION TON OTAL FEE ANOH STATE THAT EREBY ACKNOWLEDGE EADBOVE THAT C ORRECT AND AGREE I HAVE READ THIS ATOLJNO WITH ALL COUNTY ORDINANCES AND STATE LAWS REG 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON, PLUMBING AND SEWERS. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I HEREBY CERTIFY THAT I AM PROPERLY REGI TERED ICATION TO THE PUBLIC SEWER. LICENSED AS REQUIRED BY LOS AN S COUN AND ST SIGNED THIS DAY OF 19_ CALIFORNIA OR THAT HE L A OWNER F. AND INTOWNER OR RESIDE IN. THE A VE DES RIB ESIDENTI L PROPERTY +'OWNERS AGENT SIGNATURE ADORES OF PERMTTTE VALIDATION CK. M.0 CASH ` 6 o� ;UL u e 1 5:0 0 Q ,� WORKERS' CQMPENSATION DECLARATION !� I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D c. 38,Job.-C.) COE5808(REV 8/81) gppLICATION FOR PE MIT pony El CCertified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Fi Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. �/ Date./--. Applicant t� 7 FOR APPLICANT TO FILL IN CONNECTION DATA CERTIF ATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS—J 4!Z7 / 9 ��(�� rloN DEPTH (This section need not be completed if the work involved by theLOCALITY �. •��' UPPER OWER MANHOLE REFERENCE permit is for one hundred dollars ($100)or less.) NEAREST. TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS S 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. BC.NO. J OWNER i .� O.IMP.NO. OB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. comply with such provisions or this permit shall be deemed HWY.OR ST.WIDENING revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONNo.OF BLDGS. j PERMIT NO. SIZE OF LOT NO 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 BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. `�, / CONTRACTOR CONNECTION CHARGE FEE License N mb L�t/ YCl.Id55 ADDRE ~� BURSEMENT FEE C tr iSF _�� tf@��" /��) 7 DISTRICT NO, G OUP MAP PR ES D BY CITY ✓j ,�� /' BK PG ❑ I am exempt under Sec Of the L.A.Co. STATE LICENSE NO. QL `� CLASS G T S� fil 16 / NO. DESCR PTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL VALIDATION HOUSE SEWER CONNECTING TO DATE ✓ B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY e PRIVATE DISPOSAL SYSTEM Signatur CONNECT ADDITIONAL BLDG.OR WNER-BUILDER ECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE b 41.4 A fessions Code): SEWER OR DISPOSAL SYSTEM z ❑ 1,as owner of the property,or my employees with wages as # 0.0 0 0.1 0 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business o o 2 1,5.0 and Professions Code). OWNER'S Permit $ lTU ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE o 0 0 2 l,5 Q= c� licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 01.27,-87 2 r/g aV 7 CONSTRUCTION LENDING AGENCY ' / 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 Lender's Name Lender's Address I certify that I have read this application and state that the above informat10n is correct. I agree to comply with all County ordi •nces and State laws regulating Plumbing and Sewers, an hereby authorize representatives of his County to enter u on the above-mentioned property for in pecti purposes. f m ee ate SEE REVERSE FOR EXPLANATORY LANGUAGE tY , 'WogKERS'COMPENSATION DECLARATION L' 1, ere ypffirm. that I Have a certificate of consent to self }I insure, or a certificate of Workers'Compensation Insurance, or 76A642D U a certified copy thereof (Sec. 3800,�� CE 808iREV.1/831 APPLICATION FOR PERMIT Policy No. - Company __ __ __ /I�&z ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is'filed with the county b ilding inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date 2r Applicont ��� FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION 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 NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this 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. OWNER CO.IMP.NO. !OB NO. MAIL Date Applicant • ADDRESS TRUNK PERMIT °', ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making CITY TEL.NO. this Certificate, of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 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 0 Lic.Class ADDRESS REIMBURSEMENT FEE COnirOClOr !//� Dat@ '%GY/r�..J _ DISTRICT NO. GROUP MAP PROCESSED BY "•'`/// CITY TEL NO. rr�/ rt� STATE LIC. BK PG ( 'Y ❑ I am exe pt under Sec. of the L.A.Co. LICENSE NO. CLASS Plumbing Code and/or Sec. of the NO: DESCRIPTION OF WORK FEE IO FINAL /// _ , HOUSE SEWER CONNECTING TO DATE / ✓ VALIDATION �' B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FIN Date PITS AND/OR DRAINFIELD ¢/g HOUSE SEWER CONNECTING TO Z PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR / /� , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER Y/ ;91 7 6 3 A OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- SEWER REPAIR OR DISPOSAL S ABANDON HOUSE # 0 0 0 0 1 0 fessions Code): 1'003250 ❑ I,as owner of the property,or my employees with wages as 0 0 - 325010 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 03.29-85 and Professions Code). OWNER'S Permit $ ja ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE dTRO licensed contractors to construct the,project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTBusiness and PfofesSions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.ACONSTRUCTION LENDING GENCYI hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1 for the performance of the work for which this permit is OWNER OWNERSAGENT issued (Sec. 3097, Civ. C.). ADDRESS ' 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 ordinances and State laws regulating Plumbing and Sewers, and hereby au orize representatives of this County to enter upon the ob a-me toned property for inspection purposes. gnature of ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE