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Home My Public Portal About10534 FREER ST_Sewer__ DEPARTMENT OF COUNTY ENGLYF.ER SEINER-SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER BUILDING ADDRESS 0 FOR APPLICANT TO FI L IN LOCALITY tea. BUILDINGNEAREST / Q [– �/ _ nJ CROSS ST. ADDRESS • LOCALITYC�/S.tA DISTRICT NO. SERA. PERMMIIIT' NO. r NEAREST }� 9 A / 31 CROSS ST. 5 W y,_ — RE El Ready for Inspection Dl}rfE ISSUE OWNER MAIL ® c_ "s�Q�J USE ZVV OCCUPANCY BK PG MAP ADDRESS6� J Q / Q CITY 'f.Lyv"6 t TELAO. CONTRACTOR GAP--"— CO.IMP.N0. ADDRESSJOB.N0. � CITY TEL.NO. TRUNK PERMIT NO. STATE REGISTRATION NO. COUNTY ROAD PERMIT NO. LEGAL �] STATE ENCROACHMENT DESCRIPTION LOT N0. U� PERMIT NO. BLOCK TRACT r%> -1 b INDUSTRIAL NO.OF WASTE APPROVAL SIZE OF LOT NOW ON LOTS CHARGES USE OF I „ BUILDINGS W�CTVK_%. CONNECTION CHARGE FE NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLICSEWER @ $ 3.50 RECEIPT NO. DATE IBY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR XCEPTIONCORDED WORK TO HOUSE SEWER - 1.00 O ALTER OR REPAIR EXISTING DA IBY _SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER _ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR pp�� PITS AND/OR DRAINFIELD 2.00 STATION � (9 DEPTH m CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2.00 O®� MA UPP FERENCE .601WOR TYPE OF CONNECTIO7-0`10) LENGTH FROM OWNERS PERMIT $ I I 00 M.L.TO P.L. �J AUTHORIZATION I TOTAL FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER `_ �p SIGNED THIS____............DAY OF._-_.��.__ 19�N NEW HOUSE SEWER SG1iY D r i� OWNER OR �(� CONNECT ADDITIONAL OWNERS AGENT-....'."A _ BUILDING OR WORK ./I ....._.- ADDRESS......JD.t��.u--___-_--1= /�. SEPTIC TANK,SEEP.PIT(S) ....._._. ....__._.__... �.__ AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 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 DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE-SEWER AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS _ SIGNATURE ')�A'41 SEEP.PIT(S)E] CESSPOOLS E] OF PEP,MITTEE. _ .____e '�� "! `�__�.'_. 76A642A 663 7/53 4O KR ERS'COMPENSATION DECLARATION form that I have a certificate of consent to self f a certificate of Workers'Compensation Insurance, or 76A6426 tified copy thereof (Sec. 3800, Lab C.) 92-0092 DPW 6/88 APPLICATION FOR PERMIT olicy No. Company rA ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING _ COMPENSATION INSURANCE ADDRE STATIGN 3� DEPTH (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE — UPPER permit is for one hundred dollars ($100)or less.) R NEARFST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST v cuRe L 'MA TOP L permit is issued, 1 shall not employ any person in any m nner so as to become subject to the W rs'Compen tion L ws. OWNFR ! CO IMP NO JOB NO MAIL /� f TRUNK PERMIT NO ROAD PERMIT NO DoteApplicant ADoarss NOTICE TO APPLICANT: If, after making this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD IN$TR NO DATE CIT 4 Exemption, you should become subject to the Workers' LEGAL TEL NO � 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 TATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO I hereby affirm that I am licensed under provisions of Chapter SIZEGF LOT NOW ON LOT 9 (commencing with Section 7000) of Division 3 of the BU51- USE BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR �) CONNECTION CHARGE FEE ' License Number Lic.Classes ADDRESS �V REIMBURSEMENT FEE COntraCt Date /A L1� _ CITY :� �L ' 3-� DISTRACT NO GROUP MAP PROCESSED BY ' 7TTT��T K ^PCi ❑ 1 am exempt under Sec. of the L A.Co. NO LICENSE NO CtCnss '�/ , [ Plumbing Code and/or Sec. of the NO E RIPTION OF WORK_ FEE FINAL HOUSE SEWER CONNECTING TO /� DATE / •^-� VALIDATION B. 8 P. Code for the following reason PUBLIC SEWER �J SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL i Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM ' ! Signature CONNECT ADDITIONAL BLDG.OR / OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER i OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE r I Law for the following reason (Secton 7031 S, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 3307 .10 fessions Code): SEWER OR DISPOSAL SYSTEM .. - VOID ❑ I, as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure 3307 is not intended or offered for sale (Section 7044, Business and Professions Code). I OWNERS Permit $ 10 ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE AC.U.i licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A NTRACT WITH THE HEREIN NAMED CONTRACTOR TO c Business and Professions Cade). CONNECT THE ABOVE DE BE XISTING DWELLING TO THE PUBLIC SEWER »�7 44 y{O CONSTRUCTION LENDING AGENCY v SIGNED THIS 4Y 19_ ® I ITEMS- for hereby affirm that there is a construction lending agency - ! for the performance of the work for which this permit Is OWNERS AGE / issued (Sec. 3097, Civ. C.). OWNERTOTAL 40. 15 lender's Name ADORES$ CHECK Lender's Address -HANUE 4■35 1 certify that I have read this application and state that the ab in is correct. I agree to comply with all County o din ces and State lows regulating Plumbing and Sewers, 0000-0001 IJ 5/85 nd ereby authorize representatives of this County to enter upo the above- boned pr erty for inspection purposes. - 7301 1 AM 3:54 -r SEE REVERSE FOR EXPLANATORY LANGUAGE 1!