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Home My Public Portal About5606 GOLDEN WEST AVE_Sewer__ DEPARTMENT OF COUNTY ENGOMER SEWER—SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER I BUILDING ADD ESS Gp,<,D,ErfJ�aJ ter/ FOR APPLICANT TO FILL IN ' NEARELOCALST TY L _ BUILDING / "-�^1 f-- NEAREST ADDRESS �b �J k� G`S/ CROSS ST. LOCALITY DISTRICT NO SERIAL NO. PERMIT NO. C NEAREST ✓S _ J CROSS ST R CEIVED BY Ready f r Inspection DATE ISSU D OWNER /1) %54 � r MAIL e ADDRESS xf(� t� S t1 _ZONE OCCUPANCY BK MAP PG CITY �-/_ LC-- o N0. '( CONTRACTOR CO.IMP.NO. ADDRESS JOB.NO. / CITY TEL:NO. TRUNK PER IT NO. / STATE REGISTRATION WO. COUNTY ROAD PERMIT ko . LEGAL 16" / S� �/G �F•/ STATE ENCROAC MENT DESCRIPTION LOT NO. PERMIT NO. BLOCK TRACT �� INDUSTRIAL WASTE APPROVAL -jj+ // NO.OF SLOGS. SIZE OF LOT CHARGES NOW ON LOT USE BUILDINGS CONNECTION CHARGE E NO. DESCRIPTION O ORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECT G TO - PUBLICSEWER $ 9.80 RECEIPT NO. DATE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM LGO -CONNECT ADDITIONAL BLDG.OR EXC PTI N RECORDED WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING NO ATE I BY SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER _ AND/OR DISPOSAL SYSTEM 1.00 CONNECTIO DATA SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD 2.00 STATION DEPTH CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2.00 MANHOCE UPPER EFER LOWER T PE OF CONNECTION LEN TH FROM Y. OWNERS PERMIT 1 00 CURB P.L. M.L.T P L. ; I AUTHORIZATION TOTAL FEE Oa CONTRACTOHAVE IS DATE R TO CONNECT THTED WITH THE E ABOVE DESCRIBED EXISTING ED APPROVALS INSPECTOR'S SIGNA URE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS---__-.__...DAY OF-._..____________19..._.. NEW HOUSE SEWER OWNER OR., CONN T WORK ADDITIONAL .".. OWNERS AGEN,� 1 - .._.._. to 1C SEPTIC TANK,SEEP.PIT(S) ADDRESS ---------------.---------..--.._._..-..._.--------------------. AND/ORDRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL E] DRYWELL E] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE 'TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER. REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STAT OF CALIFORNIA OR THAT I AM THE LEGAL OWN. i ER OF TH ABO DE CRIBED SIAEWTIAL PROPERTY. BACKFILL SEPTIC TANKS SIGNATURE l-I SEEP.PIT(S)� CESSPOOLS E] OF PERMIT. ... -- _. .. _ ------- --_. ,� 76A642A 6637/5 WORKERS' COMPENSATION DECLARATION I h'ere£1'yw Firm that I have a certificate of consent to self .'I iivrB',�,a certificate of Workers'Co ensatio Insurance, or 76A642D a certified vQlF .Ionic 3800 C ) CE 808(REV B,B)) APPLICATION FOR PERMIT Policy No ��'�L ompan _ Os ' Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL Certified copy is filed with he county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Doter' .1'Apphcant FOR APPLICA T TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING STATION U �� DEPTH COMPENSATION INSURANCE ADDRESS CCCJJJ ddd (This section need not be completed if the work Involved by theMANHOLE REFERENCE �tJ PIPERpermit Is for one hundred dollars ($100)or less ) LocALIr Swc NEARE I certify that In the performance Of the work for which this CROSS ST TYPE OF CONNECTION LENGTH FROM permit is Issued, I shall not employ any person in-any manner Y CURB PL M L TO P L so as to become subject to the Workers'Compensation Laws P C NO OWNER CO IMP NO JOB NO MAIL Date Applicant ADDRESS TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If, after making this Certificate Of 2&yAFFIDAVIT NO AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE 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 BIDGS PERMIT NO SIZE OF LOT NOW ON LOT - ,. '^ •L—� DI hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES Hess and Professions Code, and my license Is in full force and — ='-I•'.: effectCONTRACTO Vol, CONNECTION CHARGE FEE L•Icense kL bLIC Class ADDRESS Q REIMBURSEMENT FEE Q COntraC r Dote/�� j� DISTRICT NO GROUP MAP PROCESSED BY V 'CITY TEL NO STATE LIC BK PG O ❑ j am exempt under Sec of the L A Co LICENSE NO CLASS NO DESCRIPTION OF WORK FEE / V Plumbing Code and/or Sec of the FINAL HOUSE SEWER CONNECTING TO DATE 7��/ VALIDATION N B 8 P Code for the following reason PUBLIC SEWER / SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/CR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN,CESSPOOL,DRYWELL,MANHOLE Law for'the'following reason (Secton 7031 5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE -" fessions Code) SEWER OR DISPOSAL SYSTEM p ❑ 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) OWNERS 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 TOL Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLIA TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCY 'J _i'f-:4 o� I hereby affirm that there is a construction lending agency SIGNED THIS F 1 for the performance of the work for which this permit Is OWNER OR -` issued (Sec 3097, CIV C , OWNERS AGENT ADDRESS "`•t T' �1 i:! r•-, _`•._� :I.__'_L:�( �� ..�i Lender's Name 3P Lender's Address t T i--4 MH I certify that I have read this application and state that the above Information Is correct I agree to comply with all County :77: ordinances and State jaws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter :rY rQ u on the ab ntioned property for inspection purposes 01. / 17.1 Signature of Permittee ate SEE REVERSE FOR EXPLANATORY LANGUF i6_� �' ` ,�r� 0 i-.i