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Home My Public Portal About5347 ENCINITA AVE_Sewer__ 76A642D APPLICATION FOR PERMIT S a E-663 3-55 DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL — Dep=tment of County Engineer B UILDING County of Los Angeles 5-347 C_Na/lr/-ni WM.J. FOX. COUNTY ENGINEERCASSATT D. GRIFFIN, SUPT OF BUILDING `,G NEAREST FOR APPLICANT TO FILL IN CROSS STS./®L/ V `�y � G /�V7 � LEGAL *'®�t�Ll,� G OWNER, w A Ana �F�� #d/ ag DESCRIPTION LOT N0. '° BLOCK TRACT MAIL �n r __ADDRESS JaP/ ��f yam!/f(/'7 NO. OF BLDGS. SIZE OF LOT > �,�5�$p(';,,f�/�f, NOW ON LOT CITY _ EL. NO. USEBUILDINGS 1`V «. t�FYC' DISTRICT N0. I P AIBP BK PG CONTRACTOR ADDRESS a. CONNECTION DATA O CITY TEL. NO. STATION 9 DEPTH ❑ STATE MANHOLE REFERENCE REGISTRATION NO. ❑ COUNTY g CLOWE - NO. DESCRIPTION OF WORK FEE yypp� HOUSE SEWER CONNECTING TO TYPEQCUF2B��CTIO ;ELGTOH P 1.0M PUBLIC SEWER @ $ 3.50 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 COADDITIONAL BLDG. OR 0. 1-37 7 JOB NO0 _ WORKRK TO TO HOUSE SEWER 1.00 CO. IMP. N ALTER OR REPAIR EXISTING EWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.j�// S DIS ONNECT AND ABANDON SEWER STATE ENCROACHMENT AN /OR DISPOSAL SYSTEM 1.00 PERMIT NO. - SEPTIC TANK, SEEPAGE PIT OR PITS AND/OR DRAINFIELD .00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CHARGES PERMIT CONNECTION CHARGE FEE OWNER'S s 1 o0 — AUTHORIZATION TOTAL FEE CSl REIMBURSEMENT FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEW DAY OF r /• 19 NEW HOUSE SEWER SIGNED THIS ONER OR CONNECT ADDITIONAL OWWNERS AGENT _ 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 IHEREBY 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 TH}jE ABOVE ABANDON HOUSE SEWER. , DESCRIBED RESIDENTIAL PROPERTY, d��C/�^-�✓ BACKFILL SEPTIC TANKS❑ gg r} SEEP. PIT(S) (_1 CESSPOOLS f `7 .df-,-:�ff%•' L SIGNATURE OF PERMITTEEh - WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR E# 0 3 9 3- SEP2 0 4 4.50 m 1 WORKERS'COMPENSATION DECLARATION I fierekiy ,orfirm i'(at I have a certificate of consent to self }I insure, or a certificate of Workers'CompeAsation Insurance, or 76A642D U a certified copy thereof (Sec. 3800, Lab C. CE 808(REV.1/83) APPLICATION FOR PERMIT e(C yNo. SEWER - SEWAGE DISPOSAL Company ertified copy is hereby furnished. ertified copy is filed with the unty buil ' inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY depart nt. Date is �yplicant FOR APPLICANT TO FILL IN CONNECTION DATA ERTIF C TJOF EXEMPTION FROM WORKERS' FDDRE COMPENSATION INSURANCE �C �� STATION DEPTH (This section need not be completed if the work involved by the t MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) � d (OWER TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any mannerso as to become subject to the Workers'Compensation Laws. P.C.NO. CO.IMP.NO. JOB NO. TRUNK PERMIT NO. ROAD PERMIT NO. DateApplicant NOTICE TO APPLICANT: If, after makin this Certificate Of �! AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g ' EL.NO. Exemption, you should become subject to the WorkersLEGAL 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 PERMIT No. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF cc _ 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS )o CHARGES ness and Professions Code, and my license is in full force and effect. 9✓.�{{r CONTRACTOR CONNECTION CHARGE FEE License Number Xt�Lic.Classy ADDRESS eFar REIMBURSEMENT FEE Contractor Date DISTRICT NO. GROUP MAP PR CESSED BY 0. CITY TEL.NO. 0--1q7_ yof .^//�� BK G,PG ��//�J/JJQ,Jn�,,, 0 ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS 0-` 16S T �/+ �/ 99 Plumbing Code and/Or Sec. of the NO. DESCRIPTION OF WORK FEE FINALO -HOUSE SEWER CONNECTING TO !7 DATE •--. i VALIDATI/ i7 0 B. & P. Code for the following reason PUBLIC SEWER (�' U � W SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM YNZ20-9 IL 2 A Signature CONNECT ADDITIONAL BLDG.OR ' OWNER-BUILDER DECLARATION WORK TO HOUSE SEWERL J� �I #•010 0 0 1 Q OVERFLOW SEEPAGE PIT,DRAINFIELD 1 i / 1 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 SYSTEM HOUSE o o27,50 fessions Code): ❑ I,as owner of the property,or my employees with wages as o o o 2 7 5 0 6 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business I Q 23-84 and Professions Code). OWNER'S Permit S j ❑ I,bs owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED O-TRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY poolI hereby affirm that there is a construction lending agency SIGNED THISDAYOF OWNER �%�_ for the performance of the work for which this permit is OWNERSOAGENT 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 authorize representatives of this County to enter upon th bove-m5pUcrtycl property for inspection purposes. ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE