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Home My Public Portal About5135 FARAGO AVE_Sewer__ DEPAR OSP' 000lfrY ENGI EZB SEWER®SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY I C UD= OF LOS Axa � PERMIT APPLICATION WILLIAM J FOX, COUNTY EHIOINIER I BUILDI ADDRESS 5-� S Mahe-ad� FOR APPLICANT TO FILL IN LOCALITY ^ Q� BUILDING 13 NEAREST ADDRESS A A-� / CROSS ST 'y'n l"y LOCALITY DISTRICT NO Ready for Inspection PERMIT NO C NEAREST / , S I 6 z 76 J CROSS ST �( ^ /�> A' � A� y, REC IVED 8Y DATE SSUED BY DATE OWNER ' ✓-JYJ �� MAIL ADDRESS USE ZONE OCCUPANCY BK MAP PG �/I Ah n _I CITY TEL NO CONTRACTOR 8 ! Orn/8 ewer Lonstructioll EL CO IMP NO ADDRESS 1317 Colegrove Avg JOB NO CITY onea T�L NO a r c,r is TRUNK PERMIT NO REGISTRATION NO l / q qs STATE ROAD PERMIT NO LEGAL DESCRIPTION LOT NO STATE ENCROACHMENT PERMIT NO BLOCK TRACT / INDUSTRIAL 75 �0-10 WASTE APPROVAL SIZE OF LOT NO OF SLOGS NOW ON LOTT CHARG USE OF BUILDINGS f3 CONNECTION CHARGE FEE NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER 0 $ 350 RECEIPT NO DATE BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG OR ` EXCEPTION RECORDED WORK TO HOUSE SEWER 1 00 ALTER OR REPAIR EXISTING NO I DATE I B SEWER OR DISPOSAL SYSTEM 1 00 DISCONNECT AND ABANDON SEWER AND/OR 018POSAL SYSTEM 1 00 CONNECTION DATA SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD 2.00 STATION 7 DEPTH CESSPOOL-RYWELL SPECIAL CONDITIONS ONLY 200 / Q MANHOLEREFERENCEEFERENCE -LOWER. TYPE OF CONNECTION LENGTH FROM n 6 OWNERS PERMIT ; I 00 -GV*0— P L -ML TO P L AUTHORIZATION TOTAL FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED , CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORS SIGN TURF DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS AY O NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS _ EPTIC TANK SEEP PIT(S) AND/OR DRAINFIELD 1 HEREBY ACKNO ED T AT 1 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 SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED A D/OR LICENSED AS REQ RED BY LOS ANGELES COUNTY DISCONNECT PLUG AND A�D STATE OF I RNI OR HAT I AM THE LEGAL OWN ABANDONHOUSE SEWER ER OF THE SC E SIDE TIAL PROP Y KF LL SEPTIC TANKS E] SIGNATURE SEEP PIT(S)C] CESSPOOLS OF PERMITTE 76A642D SSE 663 4/64 Ao` + a kVORKERS COMPENSATION DECLARATION frhereby-r7ffirm that I have a certificate of consent to self Insurd or a certificate of Workers Compensation Insurance or 76A642D a Certified y thereof (Sec 3800,Lt}b CCE S08(REV 8/B,> APPLICATION FOR PERMIT Policy No Company �/ -xl— CE5 ❑ Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departure th ' k Date/—/—�U Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FRO WORKERS BUILDING —(I— ,c— / COMPENSATION INSURANCE ADDRESS3. /!C STATION 7DEPTH (This section need not be completed if the work involved by the o MANHOLE REFERENCE O t �O PPER permit is for one hundred dollars ($100)or less ) i LOCALITY LOWER I certify that In the performance of the work fair which this ICROSS NEAREST TYPE OF CONNECTION LENGTH FROM / Y CURB PL ML TOPL permit Is Issued I shall not employ any person In any manner f P c No so as to become subject to the Workers Compensation Laws OWNER ps CO IMP NO JOB NO MAIL TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS AI NOTICE TO APPLICANT If after making this Certificate Of n AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE Exemption you should become subject to the Workers c1TY /y TEL NO -1 9 Compensation provisions of the Labor code you must forthwith LEGAL P P Y , DESCRIPTION LOT NO HWY OR 5T WIDENING comply with such provisions or this permit shall be deemed revoked BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO 1 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 G/T�/ '-- ie i CONNECTION CHARGE FEE a License Number 903/3 LIC Class �� ADDRESS (i J� S� REIMBURSEMENT FEE O COntracto Date J/ DISTRICT NO GROUP MAP PROCESSED BY U V F- CITY TEL NO 3�D/ P LICENSE NO CLASS BK PG 0 ❑ I am exempt t under Sec of the L A Co STATE LICCL // ')� �_� 6 � C.. F NO DESCRIPTION OF WORK Plumbing Code and/or Sec of the FINAL U HOUSE SEWER CONNECTING TO 0� DATE Z VALIDATION LU PUBLIC SEWER B & P Code for the following reason to CL SEPTIC TANK SEEPAGE PIT OR FINAL Date / —o�O- PITS AND/OR DRAINFIELD B HOUSE SEWER CONNECTING TO _ PRIVATE DISPOSAL SYSTEM Signature -1 CONNECT ADDITIONAL BLDG OR �IeWNFR Fit ILDE ECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD �� I hereby affirm that I am exempt from the Contractors License EXTN CESSPOOL DRYWELL MANHOLE Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE _ - fessions Code) SEWER OR DISPOSAL SYSTEM ACCT AT ❑ 7•T �(I as owner of the property or my employees with wages as ;� VV Lr,•% their sole compensation will do the work and the structure - Is not Intended or offered for sale (Section 7044 Business 1 ITM and Professions Code) OWNER'S Permit $ 16 8 __ TOTS ❑ j as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE (� ll nsed conctors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO QV CKCK •50 Bus estras and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHANK CONSTRUCTION LENDING AGENCY "' ��N1L� • I I hereby a m that there is a construction lending agency SIGNED THIS DAY OF 19�*' for the perfor once of the work for which this permit is OWNER OR Poo Issued (Sec 309 IV C ) OWNERS AGENT '�1 /+}3/Qp ADDRESS X 46.5 � AM10•26 ` Lender s Name f770� 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 r ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon above mentlo ed property for inspection purposes Signature o Per ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE