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Home My Public Portal About10526 FREER ST_Sewer__ 0-63 76A642D APPLICATION FOR PERMIT 6A642u COUNTY OF LOS ANGELES I SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS G`Y WILLIAM A. JENSEN, Sup't of Building LOCA LiTY NEAREST FOR APPLICANT TO FILL IN CRD55 ST LEGAL DESCRIPTION LOT NO OWNER MAIL BLOCK TRACT ADDRESS O OF BLDG SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO[GT PK MAP PG PROCES ED BY oeCONTRACTOR ADDRESS d CONNECTION DATA CITY EL NO. ! ! STATE lJ STATION DEPTH MANHOLE REFERENCE REGISTRATION NO ae, 5/7 ❑ COUNTY NO DESCRIPTION OF WORK FEE Y. YPE OF CONNECTION LENGTH FR HOUSE SEWER CONNECTING TO }{� CURB P L M.L TO P.L. PUBLIC SEWER @ $5 00 q/ v 0- SEPTIC TANK,SEEPAGE PIT OR PC.NO JOB NO O PITS AND/OR DRAINFIELD @ E10.00 CO IMP. NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO. V / PRIVATE DISPOSAL SYSTEM $300 / C9 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR.NO. DATE O WORK TO HOUSE SEWER @ $300 OVERFLOW SEEPAGE PIT,DRAINFIELD W EXTN,CESSPOOL,DRYWELL.MANHOLE @ $5 00 HWY.OR ST WIDENING ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT L• PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT S z ov�0��.� AUTHORIZATION TOTAL FEE v V CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TOCONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER ! �)� c OWNERS AGENT CONNECT ADDITIONAL il BUILDING OR WORK ADDRESS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PITT S) AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOV DESCRI ED RESIDENTIAL PROPERTY ABANDON HOUSESEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE ❑ SEEP,PIT S) ❑ CESSPOOLS ALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CK M O CASH LALOb332:0 MA1' 9 1 4 A 700- tiC/ WORKERS' COMPENSATION DECLARATION I hereby affirm that.1 have,q certificate of consent to,self insurtt?•4.lr a certificate of Workers'Compensation Insurance, Or 76A6420 o'certified copy thereof(Sec. 3800, Lab C.) 92-0002 DPW 6/88 APPLICATION FOR PERMIT- Policy No. Company p ❑ 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 COMPENSATION INSURANCE ADDRESS _ A&W Arin� srnnoN 3'� oEPTH (This section need not be completed If the work involved by the LOCALITY MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less.) f- ER I certify that in the performance Of the work for which this CROSSNEARESST TYPE OF CONNECTION LENGTH FROM permit Is issued, I shall not employ any person in any m nner Y CURB L M L TO P'L so as to become subject to the W rs'Compen tion L ws. PC NO OWNER - CO IMP NO JOB NO MAIL TRUNK PERMIT NO ROAD PERMIT NO Date Applicant ADDRESS NOTICE, TO APPLICANT: If, after making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE Exemption, you should become subject to the Workers' Cir TEL NO 3 o Compensation provisions of the Labor code, you must forthwith LEGAL P P Y DESCRIPTION LOT NO HWY OR Si 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 Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE Contract Date / -�: LI/ �� CITYVJ* 3i '73 DISTRICT NO GROUP MAP PROCESSED BY TEL NO / BK PG r ❑ jam exempt under Sec of the L.A.Co. STATE NO CLASS �.� 3 I V CL Plumbing Code and/or Sec. of the NO E RIPTION OF WORK FEE FINAI OU HOUSE SEWER CONNECTING TO 64 DATE VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER D dr- SEPTIC Y SEPTIC TANK,SEEPAGE PIT OR 0 PITS AND/OR DRAINFIELD FINAL (— Date HOUSE SEWER CONNECTING TO BY W PRIVATE DISPOSAL SYSTEM _ _ Signature CONNECT ADDITIONAL BLDG,OR 0- U)OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD z I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE r Law for the following reason (Secton'7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 3301 •��s feSSiOr1S Code): SEWER OR DISPOSAL SYSTEM ••,,.. . ID F-1 1,as owner of the property,or my employees with wages as i! their sole compensation, will do the work and the structure � �� —tte4 is not intended or offered for sale (Section 7044, Business df'--- CONSTRUCTION Permit $ and Professions Code). OWNER'S 10 ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE "' r• a licensed contractors to construct the project Section 7044, At•CTes P I ( I HAVE AT THIS DATE E NTRACT WITH THE HEREIN NAMED CONTRACTOR Business and Professions Code). CONNECT THE ABOVE DES IBE EXISTING DWELLING TO THE PUBLIC SEWC LENDING AGENCY 3307 44.`i0 I hereb affirm that there is a construction lendin a enc SIGNED THIS F Y 9 agency 1 ITEMS-- for the performance of the work for which this permit is OWNER OR 06 Issued (Sec. 3097, Civ. C.). OWNERS AGE T TOTAL aro m 15 Lender's Name ADDRESS C:HE�':K 44.50 Lender's Address CHANGE 4e3c I certify that I have read this application and state that the ab 0 ninformation is correct. I agree to comply with all County o din Aces and State laws regulating Plumbing and Sewers, CIOOCI_OQO1 ��f fa4� nd ereby,authorize representatives of this County to enter . 8 y upo the above- tinned pr erty for inspection purposes. 73 , - r,sl�1 1 AM °.54 IgA /r• er Itte to SEE REVERSE FOR EXPLANATORY LANGUAGE