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Home My Public Portal About9162 FORTSON DR_Sewer__ E-663 12-54 APPLICATION.,"FORR � 1 DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE I S DISPOSAL Department of County Engineer County of Los Angeles BUILDING WM. J. FOX, COUNTY ENGINEER ADDRESS • CASSATT D. GRIFFIN, 9UP•T OF BUILDING LOCALITY ll` FOR APPLICANT TO FILL IN CROSS ST. �- -od' LEGAL {� _DESCRIPTION ' LOT NO.% OWNER BLOCK %%��// TRACT f./�/� MAIL ADDRESSNO OF SIZE OF LOT6/) j\ /.F .-C! NOW ON LOTS ' CITY TEL. NO. USE OF BUILDINGS DISTRICT NQ. GROUP - MAP CONTRACTOR CALIF.SEWER CONST.CO. _ ,„� � BK PG ADDRESS 1317 COLEGROVE AVE. CONNECTION DATA CITY MONTEBELL0 TEL. NO-PA. 1-5048 STATION / 22 3 DEPTH / REGISTRATION NO. 14'8659 (STATE) ❑ COUNTY jff&i /�"y ' MANHOLE REFERENCE fff444 r �,j . UPPER LZjVMEit� TYPE 'or CONN TIO LENGTH FROM d/' No. DESCRIPTION OF WORK FEE Y•0 CURB P.L. M.L.TO P.L. HOUSE SEWER CONNECTING TO e.oA PUBLIC SEWER Q $ 3.50 _ -Z Q HOUSE SEWER CONNECTING TO - 4ff _ PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG. ORCO. IMP. NO. / Cl` JOB. NO. _ WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING _ SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD•PERMIT NO. . DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO. SEPTIC TANK,SEEPAGE PIT OR _ ITS AND/OR DRAINFIELD 2.00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 CHA < CONNECTION CHARGE FEE OWNER'S PERMIT S I 00 AUTHORIZATION TOTAL FEE <k '� REIMBURSEMENT TRACTORHAVE TTOSCONYECDATE �THEAABODVEWD S RBED EXESTINGIN ADWELLIMED ONG APPROVALS DATE INSPECTOR'S SIGNATURE' TO THE PUBLIC SEVER f /, SIGNED THIS�DAY OF I� NEW HOUSE SEWER r_,+)/ �°� � /�� OWNER OR CONNECT ADDITIONAL - r (�'f G✓_ OWNERS AGENT BUILDING OR WORK SEPTIC TANK, SEEP, PIT(S) ' ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[_1DRYWELL ElAND 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 - I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER *a" CALIFORNIA OR THAT 1 AM T E L GAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROP Y. BACKFILL SEPTIC TANKS❑ SEEP. PIT(S) ❑ CESSPOOLS SIGNATURE 14 OF PERMITTEE WILLIAM J. FOX, COUNTY ENGINEER VALIDATION -To 5.T-9 3 JUL 1 4 4.5 0 >n ,BY BY DEPUTY ` !DEPUTY :j By BY '® DEPUTY DEPUTY WORKERS' COMPENSATION DECLARATION I-hereby affirm that I have a certificate of consent to self 20-0051 DPW 6189 Insure, or a'certificaVe of Workers' Compensation Insurance, or. 76A642D a,certified copy thereof•(Se c 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 FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING / h 1� /� COMPENSATION INSURANCE ADDRESS tJ� �� I— STATION / 7. 5 DEPTH 6 (This section need not be completed If the work Involved by the �+ .� MANHOLE REFERENCE �, �y° V uPP permit is for one hundred dollars ($100)or less ) LOCALITY OWER I certify that in the performance of the work for which this CROSS ST TYPE OF CONNECTION LENGTHNEAREST M permit Is Issued, 1 shall not employ any person In any manner Y CURB P L M L P L. Z� LEGAL �^ P C NO 50 OS t0 become subject to the Workers' Compensation Laws DESCRIPTION LOT NO CO IMP NO 7® LOB NO Date Applicant 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 MAP BOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO OF BLDGS Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDFNING comply with such provisions or this permit shall be deemed USE OF revoked BUILDINGS STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION OWNER V � r �{' C G I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Bu SI- MAIL ness and Professions Code, and my license is In full force and ADDRESS ` CHARGES effectCITY I L G/ TEL NO y�r� CONNECTION CHARGE FEE l� License Number Lic Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PRO p ADDRESS S 66 BK PIS D. ❑ I am exempt under Sec of the L A Co (` } CITY TEL NO Plumbing Code and/or Sec of the STATE LIC FINAL U LICENSE NO CLASS DATE B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE VALIDATI N 0 ' HOUSE SEWER CONNECTING TO FINAL t— Date PUBLIC SEWER BY U- SEPTIC TANK SEEPAGE PIT OR Wd Signature PITS AND OR DRAINFIELD N OWNER-BUILDER DECLARATION' RIVSE SEWER CONNECTING TO a ATE DISPOSAL SYSTEM I hereby affirm that I am exempt from the Contractor's LicenseCONNECT ADDITIONAL BLDG OR Law for the following reason (Sectan 7031 5, Buisness and Pro- WORK TO HOUSE SEWER fessions Code) OVERFLOW SEEPAGE PIT,DRAINFIELD a n EXTN CESSPOOL DRYWELL MANHOLE ']a?n Qj R,REPAIR OR ABANDON HOUSE •i.: r .,- ,N` "-.• r V� ❑ I, as owner of the property, or my employees with wages as SEW "OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure Is not intended or offered for sole (Section 7044, Business I and Professions Code) ❑ I, as owner of the property, am exclusively contracting with ' licensed contractors to construct the project (Section 7044, OWNERS Permit $ Business and Professions Code) AUTHORIZATION TOTAL FEE O ,a�j CONSTRUCTION LENDING AGENCY' I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO ® 7�.7 � I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER '7 �/'�� for the performance of the work for which this permit is P issued (Sec 3097, Civ C ) SIGNED THI "%Ikc DA Y.OF. OWNER OR Lender's Name Owwc¢ir,o.F,E++T J Lender's Address ADDRESS I certify that I have read this application and state that rhe 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 ab ve-mentioned pro erty for inspection purposes \ ^ ��! I nature of P mittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE ,'