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HomeMy Public PortalAbout5432 GOLDEN WEST AVE_Sewer__ 76A"2D CE 8081REV.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 PG MAP PROCESSED BY BUILDING ADDRESS - CONNECTION DATA LOCALITY NEAREST STATION DEPTH CROSS ST. UPPER MANHOLE REFERENCE 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 WAIVER I EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT NO.OF SLOGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS STATE ENCROACHMENT PERMIT NO. CONTRACTOR INDUSTRIAL WASTE APPROVAL ADDRESS CHARGES CONNECTION CHARGE FEE pL CITY TEL.NO. pq STATE LIC. REIMBURSEMENT FEE V LICENSE NO. CLASS NO. DESCRIPTION OF WORK FEE W APPROVALS DATE INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTING TO PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER -- PITS AND/OR DRAINFIELD CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM O CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP.PIT(S) a WORK TO HOUSE SEWER AND/OR DRAINFIELD OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRYWELL❑ H 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❑ OWNER'S Permit S SEEP.PIT(S)❑ CESSPOOLS❑ AUTHORIZATION i TOTAL FEE VALIDATION 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING , TOTHE PUBLIC SEWER. SIGNED THIS DAY OF 19_ OWNER OR OWNERS AGENT ADDRESS I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION c AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. - r, I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS RE OU IRED 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