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HomeMy Public PortalAbout5426 GOLDEN WEST AVE_Sewer__ 76A642d /1 - CE8081REV.6/781 APPLICATION FOR PERMIT ©S SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT NO. GROUP BK MAP PG PROCESSED BY BUILDING ,. ADDRESS CONNECTION DATA LOCALITY NEAREST STATION DEPTH CROSS ST. UPPER MANHOLEREFERENCE LOWER OWNER TYPE OF CONNECTION LENGTH FROM MAIL .._ Y. CURB P.L. M.L.TO P.L. ADDRESS P.C.NO. CO.IMP.NO, JOB NO. CITY TEL.NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. AFFIDAVIT I WAIVER EASEMENT RECORD,INSTR,NO, DATE BLOCK TRACT NO.OF BLDGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS STATE ENCROACHMENT PERMIT NO. _ INDUSTRIAL CONTRACTOR WASTE APPROVAL ADDRESS CHARGES CITY TEL.NO. CONNECTION CHARGE FEE STATE LIC. - REIMBURSEMENT FEE O LICENSE NO. CLASS NO. DESCRIPTION OF WORK FEE APPROVALSw DATE INSPECTOR'S SIG NATUR HOUSE SEWER CONNECTING TO PUBLIC SEWER NEW HOUSE SEWER SEPTIC TANK,SEEPAGE PIT OR � PITS AND/OR DRAINFIELD CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP,PIT(S) O WORK TO HOUSE SEWER AND/OR DRAINFIELD OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ W EXTN.,CESSPOOL.DRYWELL,MANHOLE � ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS❑ SEEP.PIT(S)❑ CESSPOOLS❑ OWNER'S Permit s AUTHORIZATION I TOTAL FEE VALIDATION IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19_ - OWNEROR F OWNERS AGENT ADDRESS I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ,p / AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR - LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO RE- SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. SIGNATURE OF PERMITTEE