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Home My Public Portal About4933 FIESTA AVE_Sewer__ TEMPLE E CET CE909CE8088-59 APPLICATION FOR PERMIT 9 7 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1 DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING 3 ADDRESS JOHN A. LAMBIE, County Engineer - CASSATT D. GRIFFIN. Sup t of Building LOCALITY L NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL p DESCRIPTION LOT N0. ((ll OWNER •� T BLOCK TRACT MAIL ADDRESS r 3 /, 3 / A�/ /y SIZE OF LOT NOW ON LOTNO.OF BLDGS CITY G ," ti TEL. N0. s !.—/ 3 USE OFDISTRICT N0. GROUP ED Y BUILDINGS y S f � MAP PROCE B I BK PG• 'L..f I j CONTRACTOR �p�j/�L!'� ADDRESS 4,733 - Vd CONNECTIO DATA f /��y /7. / 1 x 73 STATION DEPTH CITY 7'- d?�I1F f C TEL.NO. esti Q+ T ❑ STATE MANHOLE REFERENCE / PER REGISTRATION NO. ElCOUNTY J/ NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 TYPE OF ION LENGTH FROM d SEPTIC TANK,SEEPAGE PIT OR Y. URB P.L. M.L.TO P.L. ITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN..CESSPOOL.DRYWELL @ $2.00 HOUSE SEWER CONNECTING TO _ P.C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 /�� - CO. IMP, N0. JOB NO. WORK TO HOUSEiSEWE��9 �r � TRUNK PERMIT NO. ROAD PERMIT NO.� � @ $7.00 ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DI POSAL SYSTEM @ $1.Q 0 _PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT g 2 00 CONNECTION CHARGE FEE A AUTHORIZATION TOTAL FEE '± V ¢s REIMBURSEMENT FEE I 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 DAY OF 19_ NEW HOUSE SEWER 'f"%( OWNER OR CONNECT ADDITIONAL ' --' OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE �j DESCRIBED RESIDENTIAL PROPERTY. SEEPFILLSEPTIC ❑ CESSP00❑LS 1it'(v SIGNATURE OF PERMITTEE 94 VALIDATIOl '} ROBERT A. WOOD CK. H.0. CASH/, SUPERVISING MECHANICAL ENGINEER o6 8 6 o J.W44 1 D 6.0 > r` WORKERS' COMPENSATION DECLARATION yf� I hereb—,affirm that I have a certificate of consent to self 200051 DPW 6189 u nsure;o a certl4icate of Workers' Compensation Insurance, or 76A642D o certified copy thereof (Sec. 3800, Lab C. APPLICATION FOR PERMIT Policy No. Company ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FAL 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 MANHOLE REFERENCE ��3 PP R permit is for one hundred dollars ($100)or less.) LOCALITY OWER NEAREST TYPE OF CON TION LENGTH FR I certify that in the performance of the work for which this CROSS ST. YP L M L TO permit is issued, I shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO JOB NO Date Applicont BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after makin this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAPBOOK PAGE PARCEL Exemption, you should become subject to the WorkersNO.OF BLDGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ness and Professions Code, and m,/license is in full force and ADDRESS CHARGES effect. CITY L.NO. CONNECTION CHARGE FEE License Number Lic. Class 7 REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED BY ADDRESS ❑ I am exempt under Sec. of the L.A. Co. �y "�? B ` �PG � _ > a CITY TEL.NO. (J ,/ L �•�iz Plumbing Code and/or Sec. of the srATELIC. FINAL V LICENSE NO. CLASS DATE VALIDATION B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE o HOUSE SEWER CONNECTING TO FINAL f" Date PUBLIC SEWER BY V SEPTIC TANK SEEPAGE PIT OR UJ IL Signature PITS AND OR DRAINFIELD N OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOPRIVATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER 10 OVERFLOW SEEPAGE PIT.DRAINFIELD feSSiOnS Code): EXTry,CESSPOOL DRYWELL.MANHOLE j/y ['T e ALTER.REPAIR OR ABANDON HOUSE ACC-1 a'E ❑ I, as owner of the property, or my employees with wages as SEWER OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure 3303 73.50 is not intended or offered for sole (Section 7044, Business and Professions Code). !!1 ITEMS El 1, as owner of the property, am exclusively contracting with OWNERS Permit $ -4,9tf_' FL ,� _ —$ licensed contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION I TOTAL FEE .1U. J!'Q CHECK 73: 0 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ONTRACTOR To � a I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 'e C. An C ltl. for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF. / I9 -I�-II �r�n1 L 171 f OWNER OR j � �p I i,Ji} Gl Y Lender's Name OWNERS AGENT II Lender's Address ADDRESS �— 7OC19 1 AIS 9a°") 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 the above-mentioned property for inspection purposes. gnature of Perm itte Date d, SEE REVERSE FOR EXPLANATORY LANGUAGE