HomeMy Public PortalAbout9603 GIDLEY ST_Sewer__ City -Of Temple Gity
CEeoe 5-85
7SA 5{2D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
D2PARTMENT OF"C,OUI'TY ENGINEER
BUILDING AND SAFELY DNISION BUILDING Ejo aidl
10BN A.LAMBIE, County Ensineer ADDR[aa
ey
COLEMAN W. JFNCINS,Suplt. o Buildins r
LOUL,ITY Te1I.I le Ci
"E"IR['T Tem le Ci Blvd.
FOR APPLICANT TO FILL IN `"°" `T� a Kavanagh
LROAL
bLOCRIPTION LOT NO. OWEH
N
R S
AIL
BLOCK 2 TRA CT21 2998 MDIDR g6og Gidle �JQ
SIZE OF LOT O X 16a9- QN LDOTS 2 C TY Tem 1pl
e �l i TEL. NO. { /
or
BUILD NG• pwolling & Garage D�FT RICT NO. ]TI MAP PE
Roc"SD BY
J & D Plumb ing C o. «o , q"- '° �1t°
CONTRACTOR
ADDRESS SQ. San Gabriel Blvd. CONNECTION DATA
CITY SanGabriel-., NO.At• 70579
STATION DEPTH
LICENSE // LICENSE
N0. 2.43896 CLASS MANHOLE R[F[R[NC[
V
No. I rESCRIFITIO64 OF WORK FEE TYPE OFC ION L GTH FR
1 HgUIE [EWER CONNECTINS TO 5 00
Y. URp P.E_ M.L.TO P.
P BLV10
C 3L1 ER • ; 5.00
[5EPTIC TANK, sLEPAsE; PIT UH F.0 NO.
PITS AN4/OR DRAINFIELD S $10.00 Co.INR Nb. JO■NO.
HOUSE SEWER CONHECTIN. TO TRUNK PERMIT NO.
PRIVATE QISPOSAL SYSTEM A S 3.00 ROAD P[RYfT NO.
N ECTg wuarl R
AFFIDAVIT •tinECORpD
.IN N A (1
WORK TO HO"E SEWER S $ 3.00'ALTER, RE PA OR
SEWER GR DISPOSAL SYSTEM S ; 9.00
HWY.OR R.WIDENING
E%TTi.,C[DS POOL, MANHOLE • S 5.00 STATE ENCROACHMENT a
PERCOLATION TEST S S 5.00 PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
OWCHARGESNER'S PERMIT s
CONN[CTIOIL CHAR°[FEE
AOTHORIZATION TOT FEE
Y NAVY AT THIS DATE A CONTRACT WITH TH[ HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC §KWER. APPROVALS D T[ IN ORY I TURR
SIGNED THIS T/ DAY OF 10_,
OWNER OR Q�f19 ry J.7'1 �.7 NEW HOUSE SEWER
OWNERS A0KKT ]]VV0 l7idl d CONNECT ADDITIONAL
ADDRESS- Temple City California BUILDING OR WORK
BEFTIC TANK,BEEP.PIT(D)
I HCIRESY ACKNOWLEDGE TWAT I HAVE READ THIS AFRLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES ANP STATE LAWS REGULATING CESSPOOL Q DRYWELL [IPLUMBING AND 8IrWKRS.
I HEREBY CERTIFY THAT I AM P P[RLY REGISTERED AND/OR ALTER,REPAIR,/EWER OR
C[
LINBED AS R[GUIRED BY LOS A Ef COUNTY AND STATE OF SEWAGE DISPO•AL SYSTEM
CALIFORNIA OR THAT I AM THE A OWNER OF, AND INTEND TQ D16CONN[CY PLUq AND
FY
[SIDE IN, THE ABO DUCRI■ R I TIAL PROPERTY, ABANDON HOUSE BIEWZR
SIGNATURE BACKFILL•SIC TANKS ❑
OF P[AHITT[[ SEEP.PIT(S) u C-K"PooLS
VALIDATION
CK. M.O. SASH
2 2 a 8% OCT14 1 0 0 7.0 0^q .4
DECLARAT10N
m that I A'crve a certificate of consent to self
RFRJKElZS'COM]PENSATIO-N
rtificate of Workers'Compensation Insurance, or xeAas2ertified copy thereof(Sec. 3800, Lab C.) CE°0°(RE"'" T) " APPLICATION FOR PERMIT
Polley No. I Company �a
❑ Certified Ropy 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' EU MDI NG f
COMPENSATION INSURANCE ADDREi6 L y ,AKN DAN
(this section meed not be Completed If the work Involved by the h~KXE RGA t�
UPP
permit Is for one hundred dollars (;100)a lea.) LOG�urY
- QM
I certL that In the performance of the work for which this Q ST. MQ ! TYPE� B OONNECnON �TM�
permit Is issued; I shall not em lay any person In any manner Y. CURB P.L M L To P.L
P.c NO.
NO-
so
ns toWAPPLJCANT.
bjed to the orken'Compensotlon Laws. OWNER L,SQk) CD.saw.NO. toe No.
TRUNK P9iMfT NO. ROAD PER WT NO-soAppllcn n2bTK:E .If, after rnaking .this Certificate � ke IT 1a No ._.�-0Aaawvrr wAtveR EASEMENT R13CORD.INSTR NO WT[
Exemption, you should b*come subject to the W Luau
Compensafion provisions of the Labor oode, you must fort th or PTtoN LOT NO.
OR V.WMEN ING
comply with such provlslgns or this permit shall be deemed '
revoked. BLOCK TRACr RATE BJ(AOACHME T
LICENSED CONTRAXrfORS DECLARATION srg of LOT Na OF%DGS- PERWT NO.I hereby affirm that I am (Icensed under provisions of Chapter W OF Now ON LOT
9 (commencing with Section 7000) of DIvlsign 3 of the Busk SULDINGS CHARGES
nen and Professions Code, and my license Is In full force and
effect. GONTRACOR CON�CHARGE PEE
License Number LIc.Class ,DDS J AJ
0
ConudCmr Date CIIY �' �� .NO. — DMTM7 NO. GROUP MAP BY
�y Z
❑ I am exempt under Sec. of the LA.Co. STATE,tom NO. � C 5a �� � � �0
Plumbing Code and/or Sec. of the PTKDN OF WORK 1$ RNAs G
HOUPSE�OONNECTINO TO DATE ® r Q. VALID ON h
B. 8 P. Code for the following reason T
Prtl Af•D SEEPAGE Prf 5-z
DRAINFE D'
Date HOUSE SEMR OON111ECnNG TO
TE
Signature c,JrrFc T ADDMONAt BLDG.OR
OWNER-BUILDER DECLARATION TO SSPOOER
OVERR. SEEPAGE
I hereby affirm that I am exempt from the Contractor's License o � = IE
Law for the following reason (Secton 7031.5, Bulsness and Pro- A1TtA REPATR OR ABANDON HOUSE
fessions Coda): R OR DaPOS4 SYSTEM
❑ I,as owner of the property,or my employees with wages as
their sole compensation, will do the work and the structure b 5 8 A
Is not Intended or offered for sale (Section 7044, Business
and Professlons Code}. OWNER'S P9rmlt s
❑ I,as owner of the property,arrf exclusively contracting with AUTHORIZATION TOTAL FEE
licensed coniraators to construct the project(Sectlon 7064, 1 HAVE AT THIS DATE A OWRAC:TWITH THE HEM NAMED WWRACTOR TO d P-• 2.1,5.Q
Business and Professions Code). CONFECT THE ADoW DEscRimD DLmTING DwRLNG FO'TrE PUBLIC SEWER;.
CONSTRUCTION LENDING AGENCY -o e ro 2 1.5.0 t3T
I hereby affirm that these Is Q construction lending agency SIGN®TH1$ DAY OF��� 19,,.._ oil,the performance of the work'for which this permit Is _0 2.19t87
OWNERS A(}9d
Issued (Sec 3097, ave C}.
ADDRESS
Lenders Name
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,
Iand hereby authorize representatives of this County to enter
u n t abovo-mentloned pr party for Inspection purpose..
Signature of Ittee to Ela PMVMU FOR EXPLANATORY LANGSUAG4