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HomeMy Public PortalAbout5465 GOLDEN WEST AVE_Sewer__ x 76A 642[',_-_CE808-10-71 APPLICATI OR PEW- AIT` fl COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING LPC-IJ W W ADDRESSJT_ 11_ LOCALITY NEAREST FOR APPLICANT TO FILL IN CROs ST. LEGAL41 DESCRIPTION LOT NO. OWNER MAIL BLOCK TRA,,//CT 13 1p�C45_ ADDRESS y��sj� SIZE OF LOT �O X ��--0 NOW OON LOTF BLD S CITY 1, TEL. NO. ,YS I(J z�6 USE OF DISTRICT NO. GROUP MAP CESSED BY BUILDINGS p. BK PG CONTRACTOR ADDRESS s.� CONNECTF14 DATA CITY n)lE c_iT v TEL. NO. �J cT 2 STATION DEPTH STATE LIC UPPERMANHOLE REFERE E LICENSE NO: GLASS LOWER NO. .DESCRIPTION OF WORK FEE TYPE OF CONNEC ON LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB L. M.L.TO P.L. PUBLIC SEWER @ $7.00 C.NO. SEPTIC'CAN K.SEEPAGE PIT OR � O PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PER p}, PRIVATE DISPOSAL SYSTEM @ $3.00 O CONNECT ADDITIONAL BLDG.QR - ��-7� AFFIDAVIT WAIVER 'EASEMENT RECORD. INSTR.NO. DATE u W -H OUSE SEWER ,F7 @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD jw EXTN..CESSPOOL,DRYWELL, @ $5.00 HWY. OR ST.WIDENING 3� O ALTER.REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT {J2 MANHOLE (� $7.00 PERMIT NO. a INDUSTRIAL H WASTE APPROVAL z OWNERCHARGES S PERMIT $ 3 AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19- OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK 7 SEPTIC TANK,SEEP,PIT(S) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSEDAS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBE�ID PROPERTY. ABANDON HOUSE SEWER SIGNATURE o BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION CK. M.O. CASH 221 "P?? SIJ D " 76AA�42D CE 808(REV 6,781 ©s APPLICAT N FOR • RMIT SEWER - SEWAGE DI OAL COUNTY OF LOS ANGELES BUILDING AND.SAFETY FOR APPLICANT TO FILL IN DISTRICT No I GROUP I, MAP7FR6M PG BUILDING ADDRESS • L �= i(/ I� CONNECTION DATLOCALITYNEAREST ., STATION - DEPTH CROSSST }. J./..�ryMANHOLEREFERENCEOWNER /. r = f •+ 4..ilVTYPE OF CONNECTION LENGADDRMAIL'ESS wYCURB PL M L TPC NOCO IMP NO ' JOB NO CITY TEL NOLEGAL TRUNK PERMIT NO ROAD PERM DESCRIPTION LOT NO AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO I a DATE^ BLOCK TRACT NO OF BLDGS SIZE OF LOT Q/�' NOW ON LOT HWY OR ST WIDENING USEOF (Y BUILDINGS STATE ENCROACHMENT ' PERMIT NO INDUSTRIAL CONTRACTOR J WASTE APPROVA ADDRESS CHARGES vv CONNECTION CHARGE FEE CITY TEL NO STATE LIC REIMBURSEMENT FEE I , LICENSE NO CLASS NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE 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 PIT(S) CONNECT ADDITIONAL4110309-UR AND/OR ORAINFIELO t7 WORK TO HOUSE SEWER ' OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL ❑ DRYWELL❑ 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 PITIS)[ICESSPOOLS❑ OWNER'S Permit s 1 1 AUTHORIZATION TOTAL FEE VALIDATION I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- - TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING A\� TOTHE PUBLIC SEWER V SIGNEDTHIS DAY OF 19_ -'� 8 �' OWNER OR OWNERS AGENT 1OI� X00 ' ADDRESSI HEREBY ACKNOWLEDGE THAT I HAVE READ THIS � AND STATE THAT THE ABOVE IS CORRECT AND AGREE TOLCOMPLY ICATION DC7 O IV '1/01.1 'O O WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING u1 O O O A,Ip PLUMBING EREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR �, O O O ER r LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF 04 — �, O � CAUFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO RE- SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY O SIGNATURE ' ``.� J}.,� J 0 O `O - OF PERMfiTEE 09n, /t ? `O O O O TL 9 ei E•883 3-89 APPLICATION FOR PERMIT DIVISION OF BUILDING AND SAFETY S EWER®SEWAGE DIS POT L Department of County Engineer County of LOS Angeles BUILDING WM.J. FOX, COUNTY ENGINEER _ADDRESS f a�19 T) CASSATT D. GRIFFIN, SUP'T OF BUILDING LOCALITY71)NEAREST , FOR APPLICANT TO FILL IN CROSS ST. L LEGAL DESCRIPTION (/ LOT NO. (/ OWNER I BLOCK TRACTI/ MAIL '� e - --K 1, `r. ,�p ��" ADDRESSxQ4' B i. - -� Pik', �j NO. OF BLDGS. SIZE OF LOT V7 NOW ON LOT CITY /,> TEL. NO USE OF BUILDINGS .. i-� DISTRICT NO. 49R0UI' MAP CONTRACTOR .5 ADDRESS �. CONNECTION DATA CITY L. STATION o DEPTH _ ❑ STATE MANHOLE REFERENCE 1 REGISTRATION NO. ❑ COUNTY 7. LOWS NO DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO TYPE ECTION LENGTH FROM PUBLIC SEWER Q $ 3 50 -Y CURB P L M L TOP L HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 100 - CONNECT ADDITIONAL BLDG. OR P C NO. WORK TO HOUSE SEWER 1 00 CO. IMP NO JOB NO ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO POAD PERMIT NO DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT T AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO. SEPTIC TANK, SEEPAGE PIT OR PITS AND/OR DRAINFIELD 00 INDUSTRIAL CESSPOOL-DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 CHARGES CONNECTION CHARGE FEE OVMER'S PERMIT 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE IHAVE MED CON. TRACTORTOCONNECT DATE O THE AABOVE CTED WDESCR DESITH THE CRIBED EXISTING EREIN A DWELLING APPROVALS DATE INSPECTORS SIGNATURE TO THE PUBLIC SEWER ' NEW HOUSE SEWER 1 SIGNED THIS - � D OF � 19 'd1�O'S OWNER OR �i CONNECT ADDITIONAL OWNERS AGENT -� 4 "I` �\T BUILDING OR WORK SEPTIC TANK,SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD 1 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 SEWAGE DISPOSAL SYSTEM IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGEL -COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT 1 AM THE LE L OWNER OF T ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDENTIA PROPERTY w- z BACKFILL SEPTIC TANKS❑ SEEP. PIT(S) ❑ CESSPOOLS m SIGNATURE OF PERMITTEE - - - WILLIAM J.FOX,COUNT ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR SEP 24 4.50 � WORKERS'COMPENSATION DECLARATION hereby affirm that I hc3ve a certificate of consent to self 92-0002 DPW 3/87Aa42D insure, or a certificate of Worke s'Compensation Insurance, or 7a76CE 808 a certified co{�y thereof (Sec. Lab C. APPLICATION FOR PERMIT Policy No. Companyny O: ❑ 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' BUILDING ,�- , STATION DEPTH COMPENSATION INSURANCE ADDRESS �VtJ= ''7— (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY ®LL G/%r LOWER NEARE I certify that In the performance of the Work for which this CROSSSST. ��c•�� V TYPE OF CONNECTION LENGTH FROM ""`���'v� Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO. so as to become subject to the Workers'Compensation Laws. OWNER U — CO.IMP,NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS 'O>(f2 AFFIDAVIT WAIVER EASEMENT RECORD.INSiR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY f® G'lY TEL.No. OQ4' v Exemption, you should become subject to the Workers' LEGAL �J Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. !1 HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT j�OS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. VV I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT k //��3 NOW ON LOT 9 (commencing with Section 7000 of Division 3 of the Busi- USE OF ( g ) BUILDINGS keHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONN ECTIO F Q/,9 License Number Lic.Class ADDRESS REIMBURSEMENT FEE O Contractor Date CITY TEL.NO. DISTRICT NO. GROUP MAP SSED BY BK PG � El am exempt under Sec. of the L.A.Co. LICENSE NO.TATE CLASS A 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL 17 U HOUSE SEWER CONNECTING TO DATE VALIDATION LU B. & P. Code for the following reason PUBLIC SEWER SEPTIC N SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIEID Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR , OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER SEEPAGE I hereby affirm that I am exempt from the Contractor's License EO TN.,OW CESSPOOL,DRYWELL, FIELMANHOLE Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM s3 j ),as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER=S Permit $ - - ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO a 3 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. _ _l t''fl_ _s" .,•, a CONSTRUCTION LENDING AGENCY /0— ZZ I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 , �'` �'0• d=-1. �^ for the performance of the work for which this permit iOWNER OR s OWNERS AGENT- •i`ls'-`ssL issued (Sec. 3097, Civ. C.). j4j�5 G�c9��/ Ctif�57-- Lender's Name ADDRESS i t'= F�i��P••�i+ Lender's Address '.•--• '=:1 =t z_.. ;j;'' _ I certify that I have read this application and state that the F.17 f•i f ;;t;�.1,-, „� above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter uponth above-mentioned_property for inspection purposes. �- Signature okpermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE