HomeMy Public PortalAbout10671 FAIRVIEW AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER � SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING /6 47 /
ADDRESS
FOR APPLICANT TO FILL INN �9/� LOCALITY
BUILDING � / �J �!> // //// NEAREST V
ADDRESS Z(J /n / /(�'//f,�/�AdI�4,�i f,/�a•<,,,/ CROSS ST �
LOCALITY , C �^ - ! DISTRICT NO SERIAL NO PERMIT NO
NEARESTw i J A /gr�5C_3' Qs
CROSS ST � j(/tiL.; �
/��� I RECEIVEDBY Ready for Inspection DATE ISSUED
OWNER
AMAILDORE S ,!/� .�P �yy /� I �!1• /�+ I��
R i USE ZONE OCCUPANCY MAP
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CITY iC�/ TEL NO d /
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CONTRACTOR � �ir i 154
CtJO ��
ADDRESS
JOB NO3�—
CITY TEL NO TRUNK PERMIT NO
REGISTRATION NO C/� '�� �G'1 SAY
ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO �� � + STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT L P ! , INDUSTRIAL
E WASTE APPROVAL
NO BF BLDGS
SIZE OF LOT NOW ON LOT CHARGES
USE OF
BUILDINGS iy 1_ _^.�, CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
_ PUBLIC SEWER to S 3 50 _�
BY
HOUSE SEWER CONNECTING TO RECEIPT NO DATE B.?
HOUSE
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR RE TING 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/ORDRAINFIELD 200 STATION �f��� (� DEPTH (p
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2 00 �7 p(,' W dJ NUPPER REFERENCE _ _
^
TYPE OF CONNECTION
*f— "CUM P L ` LENGTH FROM
OWNERS PERMIT $ 1 00 � M L TO P L
AUTHORIZATION I TOTAL FEE I
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED..
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGp APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS _ DAY OF _ _19__ { NEW HOUSE SEWER gf4
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ '� BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS _ _ _ _ _ - - a AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[:] DRYWELL
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 i I SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT IAM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS E]
SEEP PIT(S)[] CESSPOOLS
SIGNATURE 6j7
OF PERMITTEE
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