HomeMy Public PortalAbout5201 FARAGO AVE_Sewer__ E808 D
Ceaoa APPLICA ON FOR ERMIT
s sa COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMBIE County En eer
CASSATT D GRIFFIN Supt of Buildmg LOCALITY7 rk-:,
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK-� TRACT / MAIL
ADDRESS
N OF BLD
SIZE OF LOT NOW N L CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCES BY
lQd Bi(_ PG
CONTRACT (LTJ'
ADDRESS 4r CONNECTION DATA
CITY TEL NO ❑ STATION FO DEPTH 10
TATE
REGISTRATION NO ❑ COUNTY MANHOLE REFERENCE PPER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO t
PUBLIC SEWER @ $3 00 TYPE OF CONNECTIO LENGTH FROM '�f
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
ITS AND/OR DRAINFIELD @ $3 00 i
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00 '
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE EN CHMENT
PERMIT NO
i
INDUSTRIAL
WASTE APPROVAL
g.iKRGES
OWNERS PERMIT S 2 00 CONNECTION CHARGE FE
AUTHORIZATION TOTAL FEE zO- REIMBURSEMENT FE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS Do OF _ 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALLCOUNTY 0 INANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWE SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIF THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQ RED BY LOS A GELES COU Y AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR AT 1 AM THE L OW R OF THE ABOVE
DESCRIBED RES TIAL PROPERTY BACKFILL SEPTIC TANKS Cl
y SEEP PIT(S) ❑ CESSPOOLS ❑
SIGNATURE G����.
OF PERMIT
®v ATION ROBERT A WOOD
cK. I m 0 CASH SUPERVISING MECHANICAL ENGINEER
�' c 1~, 61-D CEP 1 0 0 5 t r
WORKERS COMPENSATION DECLARATION l
`I-hereby affirm that I have a certificate of consent to self
Insure or a certificate of Workers Compensation Insurance or 92-0002 DP W5/87 �
a certified copy thereof(Sec 3800 Lab C ) `78A642D
Policy No [Qy S33Company V&k dom02FF (CE 808) � � � t APPLICATION FOR PERM
IT
IF
❑ Certified copy ,s hereby furnished I SEWER - SEWAGE DISPOSAL
❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIVISION
department
Date ic;2-3/-89 Applicant Vi 1W/woll£.,_ILs FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING
COMPENSATION INSURANCE ADDRESS (�£ STATION .�^ DEPTH
(This section need not be completed if the work involved by the LOCALITY �'E t rl MANHOLE REFERENCE LOWER
permit is for one hundred dollars ($100)or less ) C'
NEAREST TYPE OF CCMINECTION "LENGTH F M
I certify that in the performance of the work for which this CROSS ST y CURB P L M L TO
permit is issued I shall not employ any person in any manner PC NO
so as to become subject to the Workers Compensation Laws OWNER co IMP NO JOB No
Al Dat@_Applicant ADDRESS S £ TRUNK PERMIT NO ROAD PERMIT NO
NOTICE TO APPLICANT If after making this Certificate of CITY �£ C TEL NO 9 AFFIDAVIT I WAIVER I 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 Bust BUILDINGS ES/ ENC CHARGES
ness and Professions Code and my license is in full force and
effect / p A CONTRACTOR f CONNECTION CHARGE FEE
License Number �6 /�� 7 3 Lic Class Cin—�p� d ADDRESS REIMBURSEMENT FEE
Contractor�//q/// /1/J ri Date 3-1/—/1 CITY ,271-�t- TEL NO 98-a�a,� DISTRICT SOUP BK MAP PG BYr 4
El am exempt under Sec of the L A Co LICENSE NO 15-6/// 73 CLASS
Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL 0
HOUSE SEWER CONNECTING TO DATE VALIDATION
B & P Code for the following reason t PUBLIC SEWER
SEPTIC TANK SEEPAGE PIT OR W
Date PITS AND/OR DRAINFIELD FINAL
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM / Zr
Signature CONNECT ADDITIONAL BLDG OR
OWNER BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractors License EOX\TIN A SEEPAGEDRIYWELRLAINFIELD MANHOLE /
Law for the following reason (Secton 7031 5 Buisness and Pro AL ERR EPAI ARAN N HOUSE O �
fess,ons Code)
r a
❑ 1 as owner of the property or my employees with wages as y 4T•r
their sole compensation will do the work and the structure 3307
v
is not Intended or offered for sale (Section 7044 Business OWNERS Permit $
1•
an'd Professions Code) 1 ITM
❑ I as 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 CONT ACTOR TO TnTA. 21..5O o
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CECT
CONSTRUCTION LENDING AGENCY P X1.50
1 hereby affirm that there Is a construction lending agency SIGNED THIS DAY OF 19_ CHAD
for the performance of the work for which this permit is OWNER OR ��71�G .00
Issued (Sec 3097 Civ C ) OWNERS AGENT
<
Lender s Name ADDRESS -W01 5/18/S9
Lender s Address M 1 AM11.09
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
andh authorize representatives of this County to enter
upo he ove mentioned property for In tion purposes
ign.t.r-of Perm, Date ( SEE REVERSE FOR EXPLANATORY LANGUAGE T