The URL can be used to link to this page

Home My Public Portal About5525 GOLDEN WEST AVE_Sewer__ C A642D 76A642 0-63 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEARE LDING ,- l� JOHN A. LAMBIE, County Engineer Eo L 1R Wa!� % WILLIAM A. JENSEN, Sup't of BuildingALITY STFOR APPLICANTTO FILL IN SS ST. j �fsi7 LEGAL DESCRIPTION LOT NO. OWNER L MAIL BLOCK TRACT �/ ADDRESS NO. OF SLOGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT N�O. GROUP MAP BK P PROCESSED BY CONTRACTOR oa '! eT^ /`� L ADDRESS Z&� N. I N ✓7L ^ CONNECTION DATA CITY L �' TEL. NO.E �(O 6\ STATION �j DEPTH JJ q V /—ISI STATE MANHOLE REFERENCE REGISTRATION NO./+� ❑ COUNTY LOWER NO. DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM HOUSE SEWER CONNECTING TO Y. CUH9 P.L. M.L. TO P.L. PUBLIC SEWER @ $5.00 ` E.✓`r P.C.NO. � SEPTIC TANK.SEEPAGE PIT OR O PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, V PRIVATE DISPOSAL SYSTEM @ S3.00 LK CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wAIVEN EASEMENT RECORD. INSTR.NO. DATE O WORK TO HOUSE SEWER @ $3.00 V OVERFLOW SEEPAGE PIT,DRAINFIELD LU EXTIN CESSPOOL,DRYWELL,MANHOLE @ $5.00 O. HWY. OR ST.WIDENING CL ALTER,REPAIR OR ABANDON HOUSE H SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT z PERMIT NO. INDUSTRIAL WASTE APPROVAL OWNERS PERMIT $ 2 00 AUTHORIZATION TOTAL FEE j OD CHARGE FEE CHARGES 'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ,/�n G '�/ APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS 3 DAY OF OWNER OR OF n i ✓moo• 19.E OWNERS AGENT �J 4.��/\1 0)o" NEW HOUSE SEWER CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP,PIT(S) I DD HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AN �OR RAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL 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 REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM .. CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED R IDENTIAL ZT ABANDON HOUSE SEWER s h SIGNATURE BACKFILL SEP TIC TANKS ❑ OF PERMITTE SEEP,PIT(S) ❑ CESSPOOL . O� ALIDATION ROBERT'A. WOOD SUPERVISING MECHANICAL ENGINEER M.O. CASH L,. G1 7 1 0 7 3 0 1 0 D 7.O 0-- WORKERS'COMPENSATION DECLARATION 92-0002 DPW 3/87 ,I hereLk'affirm that I have a certificate of consent to self 76A642D insure,-or a certificate of Workers'Compensation Insurance, or CE 808 a cehified'copy thereof (Sec. 3800, Lab C.) APPLICATION FOR PERMIT Policy No. Company Os El Certified copy isiTereby 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 af6 ZSR�o (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 (mV�— LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not employ any person in any manner subject to the Workers'Com sation Laws. T[ P. B NO. so as to become sub ppb I P OWNER J I O-" I I'�G� / CO.IMP.NO. JOB NO. MAIL�+c5" p O ' A �, TRUNK PERMIT NO. ROAD PERMIT NO. DateiZ� Applicant DDRESS eG` NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY 1.��-✓� TEL.NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF PERMIT NO. LOT SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF �// 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS /'i & 007 CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number LIC.Class ADDRESS REIMBURSEMENT FEE Contractor Date DISTRICT NO. t7p MAP PROCESS D BY O CITY TEL.NO. t V rU STATE LIC. // BK PG I am exempt under Sec. /�O�l.•.� of the L.A.Co. LICENSE NO. CLASS (f ;� Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL U HOUSE SEWER CONNECTING TO DATE VALIDATI w PUBLIC SEWER J' M B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL W PITS AND/OR DRAINFIELD — Date HOUSE SEWER CONNECTING TO BY Signature PRIVATE DISPOSAL SYSTEM 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.,VERFLOW CESSPOOL,DRYW LL, MANHOLE Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): `SEEWER OR DISPOSAL SYSTEM/I)'b ® I,as owner of the property,or my employees with wages as l -aSit lee &--,nec i o.t fo ;9 9.0 4,7 A their sole compensation, will do the work and the structure ew er Al e O n 0 A0110-0— �{ 0 0 0 o e1 0 is not intended or offered for sale (Section 7044, Business —Z 4 and Professions Code). OWNERS Permit $ :.� 0 0 2t1 rJ 0 ❑ 1,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 0 0 2 1. cJ 0' 51 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY , X2.2 cJ 8 8 1 hereby affirm that there is a construction lending agency SIGNED THIS i �DZ F 19_ for the performance of the work for which this permit is OWNER OR issued (Sec. 3097, Civ. C.). OWNERS AGENT u ADDRESS-3'V20 Lender's 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, and hereby authorize representatives of this County to enter upon the above-ment' ed property f r inspection purposes. t Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE