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Home My Public Portal About4856 GOLDEN WEST AVE_Sewer__ (2) a / APPLICATION FOR PERMIT 1 Drf imON OF B=DING AND SAFETY SEWER-SEWAGE DISPOSAL D.pcwh .nt of county F-uhu x County of Los Angeles -BUILDING JOHN A.IAMBIE, COUNTY ENGINEER ADDRESS m CAS"TT 6. GRIFFIN, SUPT OF BUILDING LO CALITT FOR APPLICANT TO FIU IN CROSS ST. LEGAL OWNER DESCRIPTION LOT N0. r/1IL BLOC[ TRACT iiz, ADDRI53 ^^ /NO.OF BLDGS. C1TT TEL, NO L srr OF LOT O NOW ON LOT USE OE DISTRICT GROUP MAP BUILDINGS R CONTRACTOR Y ' O ADDRESS � CONNECTI DATA • STATION DEPTH CITY IAN HOLE Ell UPPER STATE LOWER REGISTRATION NO. ❑ COUNTY No. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO - TYPE OF CONNECTION , DLICSEWER @ $9.50 Y. CURB t.L. Y.L TO P.L. L SEPTIC TAN[,ffiEPAGE PIT OR PI D/OR D INFIHL 8 3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD P. C. NO. EXTN.,CESSPOOL DRYWELL MANHOLE S.2.00 CO. imp. N0. O JOB N0. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEbI S 1.00 TRUNK PERIIT NO. ROAD PERMIT NO. CONNECT ADDITIONAL BLDF.OR STATS ENCROACHMENT WOR[TO HOUSE SEVER @ ER 1.00 'MM IT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM 11.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE , OVPNEE'S PE bUT $ 1 00 AUTHORIZATION TOTAL FES � � REIMBURSEMENT FES APPROVALS DATE 1NSPECTOR'aSIGNATURE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON• TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING EXISTING DWELLING TO THE PUBLIC SEWER. NEW HOUSE SEWER SIGNED THIS SAY OF 19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGENT SEPTIC TANK,SEEP,PIT(5) ADDR AND/OR DRAINFIELb I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION 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. SrWAGE PISPOSALSYSTEM I HEREBY 'CERTIFY THAT k AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED B 05 ANGEL" UNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I THE LEGA O NHR OF THE ABOVE DESCRIBED RESIDENTIA PER BACKFILL SEPTIC TANKS❑ SIGNATURE OF PERMITTEE � SEEP.PIT(9) ❑ CESSPOOL❑ 4cc— Ix - JOHN A. LAMBIE. COUNTY ENGINEER VAI.IDATIO-"" ROBERT A.WOW CHIRP PL.BG. NSP OR LAC01214 Y23 4 •A 3D4 N • T { WORKERS' COMPENSATION DECLARATION 20-0061 DM EIM I hereby affirm Out I have a certificate of consent to serf insure'orp certificate of Workers'Compensation Insurance, or - �'sM a certified copy,;bgreaL-fSec. 3800, Lab C.) APPLICATION FOR PERMIT Policy No. Company ❑ 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' EkuDiNG ��-�s COMPENSATION INSURANCE AUDFSEBE{ STATION DEPTH (This section need not be completed if the work involved by thes+nrs-OLE REFERENCl UPPER permit is for one hundred dollars ($100)or less.) LOCALrrY L IN EAR OFI certify that in the performance of the work for which this QST. r TYPEcorCURB DN P L -MLETN L TOPRL R 1>ermlt is issued, 1 shall not employ any person In qny manner CURB L LEaAL PC NO to as to become subject to the Workers' Compensation Laws. DEBOFVPTION LOT No. co MP No ypb No Date Applitant BLOCX TAT TRUNK PERMIT NO ROAD PERM NO LNI NOTICE TO APPLICANT: If, after making this Certificate of MAP PAGE PARCEL APPIOAv1 wAv� RELCRDTR No DATEExemption, you should become subject to the Workers' NO QF BLDQA Compensation provisions of the Labor code, you must forthwith EiLZE OF LOT NOW ON LOT HfWr OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BDILDIN08 STATE R4CROACHMEN1 LICENSED CONTRACTORS DECLARATION PERWT NO I hereby affirm that I am Itcensed under provisions of Chapter OWNED 11L S 9 (commencing with Section 7000) of Division 3 of the Busi- AiSDLF FSB « S no" and Professions Code, and my license Is In full force and_ effect. CTTY Ci'r TEL NO. 7, 3 CONNECTION a-LARGE FR License Number Lic. Class RE t$ CONTRACTORContractor Date DIS ICT NO GROUP MAP PROCESSED NY ADDFtE98 ex PG El �I am exempt under Sec. of The L.A.Co. DTEL 40 Of L Plumbing Code and/or Sec. of the STATE Lic. NA 8 LICENSE NO. CCAs "TE L TION Z B. 8 P. Code for the following reason POO. DESCRIFFI N OF WORK FEY 2- 41p HOUSE SEWER COr Nv iNG TO NNA �,h� Date PUIOC SEWER sr 'v■11VI . PTIC TANK PAGE PIT OR 'L TTLIii'_ r Signature PITS D OR DRAINFIELD ` i C1 k7 T OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO ir ofTOTAL 43-91% I hereby affirm that I am exempt from The Contractor's Ligense T DG OR b� GECt 43`9 Law for the following rea;an (Secton 7031.5, Buisness and Pir .CE fesslons Code): Sf£PACE HT.DRAINFIELD Ef.41 A1,yS .E" GESSPOOI,DRrWELL HOLE 4♦r�'R1lL as owner of the property,or my employees with woges as ATE R. REPAIR OR SYSTEM HIOUSE their sole compensation, will do the work and the structure SEWER DISPOSAL Is not intended or offered for sale (Section 7044, Business and Professions Code). —(=1 0000 i pp��..��y El 1, as owner of t 1 he property, am exclusively contracting with OWNERS Permit $ 4622 PM12:18 licensed Contractor} to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION I TQTAL FEE O CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE F#REiN NAMED CONTRACTOR TO 1111111.I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO T}f PU6LIC SEWER for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.). SIGNED THIS DAY OF 19_ OWNER OR Lender's Name OWnERS AGENT Lender's Address ADDRESS I certify thpt 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 hereby authorize representative; of this County to enter uro ve-mentioned property for Inspection purpo"s- / 04= )— .9 Slgnatur f PefitTee Date EEE REVERSE FOR EXPLANATORY LANGUAGE