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Home My Public Portal About9538 GIDLEY ST_Sewer__ APPLICATION FOR PERMIT 1 ■awsaff�e DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D1SPOSAL Dvp . d Comt7 Enomw of Los Ang*1" BUILDING sr JOHN A. LAMBIE; COUNTY ENGINEER ADDRESS m PA48ATT D.GRIFFIN, DUF'T OF BUILDING LOCALITY , FOR APPLICANT TO FILL IN Ift S . LEGAL OWNER DESCRIPtION LOT NO. MAIL BLOCK- TRACT ADDRESS 110. OF BLDGS. CITY TML. NO. SIZR OF LOT NOW OM LOT UOFSE BUILDINGS DISTRICT NO. GROUP MAP B BR PG CONTRACTOR ADDRESSGOIUMMON DATA / /! STATION DEPTH �• I C TEL. N0, B Y MANHOLE RinxE110E UPPER LONER REGISTRATION N0, ,a/ 2-- Q uN 'No. DP-SCRIPTION OF WORK FEE OUSE SEWER CONNECTING TO TYPE OR CONNECTION TFROM PUBLIC SEWER 3.30 Y CUR P.L. M.L.L 70O P.L SEPTIC ,SEEPAGE PIT OR PITS AMD/O DRAIRFI2LD @ 3.00 IT,Di*FNPF@S�D C M0. fQ9i. 8BDRYWELL, 2.00 CO. IMP.No. JOB NO. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM B f 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. CONNECT ADDITIONAL BLDG.OR STATE ENCROACH T WORK TO HOUSE SEWER #1.00 PERMrr NO. ' ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL - SEWER D ISP03AL SYSTEM 11.00 WASTEA�PR YAL CHARGES y ' CONNECTION CHARGE FEL OWNERS PSVT ; 1 00 AUTHORIZATION TOTAL FEE REIMEURSEME?IT FEE 1'HAVE AT 'TILS DATE A CONTRACT WITH THE flEREIK NA1ED C�- APPROVALS DATE INSPECTOR'SSLGNATURE TRACTOR TO CONNECT THE ABOVR DG3CRIBED EXISTING DWELLING TO THE PUBLIC SEWER. NEM HOUSE SEWER ' SIGNED THIS SAY OF 19 CONKECT ADDITIONAL OWNER OB BUILDING OR WORK - OWNERS AGENT SEPTIC TANK,SEEP,PIT(2) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL D AND (TATE THAT THS ABOVE 13 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOltL SYSTEM I HERYBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AN THE LEGAL O NER OF THE ABOVE _ DESCRIBED RESIDENTI ROPERTY. BACKFILL SEPTIC TANKS❑ SIGNATURE SEEP.PIT(s) ❑ CEl91-00L3 . OF PERMITTEE JOHN A. LAMBIE,CouNTY ENGINEER VALMATIpN ROBERT A.WOOD, CHIXF PLEIG. INSPECTOR CIL 2.0. ry : � 6o389 WR 3 4 A 3.00 I, WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self Insure, or a certificate of Workers'CorTipon atbn Insurance,or rsAs+so `°`"fig`'copy t`"'°°f(S°` 39°° Lob C' °e""" APPLICATION FOR PERMIT ' Policy No. - Company F-1 Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL ❑C wttfied copy Is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFM department. Date Applicant PLEG& OR AMCANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATKNJ INSURANCE L �� o�TH (This section need not be completed if the work Involved by*he E t» UPPER permit is for one hundreddoflari($100)or less.) I certify,that In the performance of the work for which this NEAREST Y. Tyre OF P.L LENGTH FROM. permit Is Issued, I shall not em oY any person In 8rry manner sq�as to become wbleci to the pensall Ltrws. �� cp.VAP.NO.. P. NO. TRUNK PER MT NO. ROAD PERW ND. TILE TAPPLICANT:IAY I nt kl this cote AFFOAVn WAIVER MSMENT RECORD.INM NO. DATE Exemption, you should me subject to the Workers' NoConN>*n atlon provisions of the Laborcode,you must forthwith LOTN .comply with such provisions or this permit shall be deerned OR�' � revoked. TRAc7 8I 3 STATE ENCROACPVAE ITwG or elDotsPERWT No. LICENSED CONTRACTORS 4ECLARATION 'x ` Now ON LOT 2 I hereby affirm thal I-am licensed under provisions of Chapter 9 (commencing with Sectlon 7000) of Dtvhlon 3 of the Bus!- CHARGES nese and Professions Code, and my license Is In full force and affect. CCHT� COHINECTFON CNAa FEE o License Number Lk.Class ADDeSS RBPABVRVA04T M% Contractor. CITYbate TEL No. DtsTRK7 NO. GROUP nw by. etc Po ElI am exempt under Sec of the LA.Co. RATE 2 LICCA NO. CI CIAEl1 Plumbing Codeand/or Sec of theNO. D$(3t moN 6F woRK FEE RNAs FK M t� M To Z I DATE V IDA O PP B:8 P. Code for the following reason PUBLIC PIT OR PtTbDRAJNR43D FINAL By Date HOU!sewm cctoecrra To Signature CONNECT DDn N DO.OR WORN a` y 1lJ OWNER-BUILDER DECLARATION � V I hereby affirm that I am exempt from the Contrvctors License ocrtl Law for the following reason (Sectop IR 7031.3, Bulaness and Pro- AL REPAOR �' fessloM Code): ort DMPOSAL SY3T&L FtOl7>sE 35.5J ❑ 1,as owner of the property,or my employees wltfi wages os 1 ITS i their sole compernation, will do the work and the atructure Is not Intended or offered for Lola.(Section 7044, Business TL�TA. 35 . 50 _ Permit (�(� and Professions Code} OWNER': ❑ I,as owner of the prop",am exclusively contracting with AUTHORIZATION TOTAL FEE DECK -,75■50 licensed contr¢ctorl to coratiuct the proled (Section 7044, 1 HAVE AT THIS DATEE-A COtiMAC.'T WTTH TFIE HERE]N N!IM)COHTRAL�OR TO • ( Business and Professions Code). C0Nf*CT THE A"M DMOMM DUTN%3 DWELUNO TO TF!PUeLK KYA31L CONSTRUCTIQN LENDING AGENCY I hereby affirm that them is a conshuctlon lending agency �OR IS DAY Of 19_ ' 0(004"1 3/28/91for the performance of the work for which this permit is QYMgZS,GrT b 1 At1111�12 IssLred (sec 3097, CIV. C.).- ADORSS Lenders Name Lenders Address I cprttfy that I have read this application and state that the above Information Is correct. I agree to comply with all County ordlnar>ces and State. Paws regulating Plumbing and-Sewers, and ' authorize representatives of this County to enter upon em to ope ly for Irrpectlgn purposes, n it s Date SE PINV=fIII KWma LAMATORY L&JOGUA04 A