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Home My Public Portal About9906 GARIBALDI AVE_Sewer__ S&E-6668 11-SS _ APPLICATION FOR PERMIT 1 S&E- DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles BUILDING JOHN A. LAMBIE, COUNTY ENGINEER _ADDRESS f ® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FILL IN _CROSS STLEGL . DESCRIPTION LOT NO ./� e" / uo OWNER A K. MAIL BLOCK TRACT at ADDRESS N0.OF BLDG'. CITY 1 TEL. NO. SIZE OF LOT `.` NOW ON LOT USE OF BUILDINGS DISTRICT NO. GROUP MAP CONTRACTOR _ ADDRESS eg' S/ _ CCONNECTION DATA CITY J A TEL. N0, 4 0 4-4&o- _STATION J I� DEPTH MANHOLE REFERENCE L'/ � � ' � UPPER ❑ STATE _ 7" REGISTRATION NO. 1.3 ❑ COUNTY NO. DESCRIPTION OF WORK FEE - HOUSE SEWER CONNECTING TO TYPE OF ION LENGTH FROM PUBLIC SEWER @ $3 0 Y. CURB) P.L. M.L.TO P,L. 00 SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELDP. C. N0. EXTN.,CESSPOOL,DRYWELL, - @ $2.00 -CO. IMP.NO. JOB NO. HOUSE SEWER CONNECTING TO /� i PRIVATE DISPOSAL SYSTEM @ $1.00 _TRUNK PERMIT NO. ROAD PERMIT N 6' CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT WORK TO HOUSE SEWER @ $1.00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM @ $1.00 INDUSTRIAL WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 00 AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER,r,�. NEW HOUSE-SEWER SIGNED THIS / DAY OFT, - G i I9 / CONNECT ADDITIONAL OWNER OR 3UILDING OR WORK - - OWNERS A SEPTIC TANK,SEEP,PIT(S) ADDRESS L4 '-�, L? i _AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ.iTHIS APP.ICATIONN CESSPOOL❑ DRYWELL❑ AND 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 1 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 CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTZLROPERT Y. J - BACKFILL SEPTIC TANKS❑ , SIGNATURE SEEP.PITS) ❑ CESSPOOLS OF PERMITTEE { JOHN A. LAMBI , COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR CK. M.0. CASH �, 3 6 1 sell ";R 1 �i 1 � A 5.00 19 WORKERS'COMPENSATION DECLARATION ' CEAB"OB2(4 8b) ^ APPLICATION FOR PERMIT � I hereby of6-m that I have a certificate of consent to self SEWER-SEW E DISPOS insury or ■ certificate of Workers'Comperuation Insurance,or a certltted copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGE ES I AFETY Policy No. Company Certified copy is hereby furnished. FOR APPLICANT TA FILL IN CONNECT( DAT ■UILD INCD �� STATION DEPTH D Certified copy is filed with the county building hupectloh woDREB■ UPPER LOCALITY ar deptment. 7z MANHOLE REFERENCE LOWER Date Applicant kKAREST ^ _ TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. le Y. CURE P.L. M.L. TO P.L. COMPENSATION INSURANCEP.c. No. OTHER 077� CO. IMP. NO. JOB NO. MAIL (Ills section peed not be completed if the work invotred ADDRAS■ TRUNK PERMIT NO. ROAD PERMIT NO. by the permit Is for one hundred dollm (3100) or Iota.) AFFIDAVIT WAIVER � RECORD.INSTR.NO. DATE CITY TEL. NO. I certify that In the performance of the work for which thisLEGAL permit Y Issued, I shall not employ any perso saner DEBCRIFnon LOT No. HWY. OR ■T. W4DENINO CC S) t become aubJect to the Co n ws. O 1 ■LOCK TRACT STATE ENCROACHMENT Dote Applicant NO. OF■LDGS. ERMIT NO. hZ; OF LOT Now ON LOT LUNOTICE T APPLICAter making this Certificate o NT: If, ft fUSK Orr tl Exemption, you should become subject to the Workers' I Compensation provtalons of the Labor Code, you must forth- BUILDINGS cHw1eGE■ Z with comply with such provislons or this permit shall beCONNECTION CHARGE FEE l deemed revoked. CONTRACTOR LICENSED CONTRACTORS DECLARATION ADDRESS ^.,CA% REIMIURSEMENT FEE I hereby affhm that I am licensed under provisions of Chapter DISTRICT NO, BROUP MAP .R c ■Eo■r CITY TEL. NO. 3J 9 (commencing with Section 7000) of DtvWon 3 of the Bwl- EN P. ' neu and Professions Code, and my license V in full force and IB.�cirEUE Nn. �3 3 LCL. G �.- /O� effect. No DRECRIFTFON OF WORK FEE OILHOUSE SEWER CORNECTING To FINAL V (DATION License Number 3 3 Lic. PLI■LIc SEWER DATA ■EFnC T NK,■EEPASE FIT OR G Contractor Date PITS AND/OR DRAINFIELD FINAL HOUSE SEWER CONNECTING TO BY PRIVJITE DISPOSAL■YSTEY A I am exempt from the ltcensing requirements as I am a CONNECT ADDITIONAL■LDS.OR licensed architect or a registered prpofessional engineer WONK TO HOU&E■AER acting in my professional Capacity (Section 7051, But OVERFLOW■EEPAGE PIT,DRAINFIELD �� `O Inas and Professions Code). ExTN.,CESSPOOL,DRrWELL,MANHOLE G ALTER,REPAIR OR ABANDON HOUSE SEWER ON DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I ■m exempt from the Contractor's OWNER'S Permit f License Law for the following reason (Section 7031.5, Buss- AUTHORIZATION I TOTAL FEE new and Professions Code): I HwvE AT rHlsDATE w tour RwR WITH THE HER IN HAYED coN- YRACTOR TO CONH NECT THE ABOVE DESCRIBED SAISTINB DWELLING I, u owner Of the property, will do the work and the TO THE PUBLIC FEWER. 23 2&7 A structure is not intended or offered for sale (Section QIQNED THIS DAY OF ts_ 7044,Business and Profesalotu Code). OWNER OR #'o o D o 1.0 OWNERS AGENT . I CONSTRUCTION LENDING AGENCY woDwEE■ 2 o Id 1 4,0 0 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit Is o,o o 4y O issued{Sec.3097,Cly.C.). 06 Lender's Name 1 203+780 Lender's Address 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 hreby autborise repr ntat of this County to enter up t tion rop or n tion purpo SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of ttee Data