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Home My Public Portal About5742 GOLDEN WEST AVE_Sewer__ n ®® ® ��py meq( PERMIT"eq-�A—p,---T 6&E-663 12.54 ' DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Department of County Engineer County of Los Angeles BUILDING WM. J. FOX, COUNTY ENGINEER ADDRESS CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY ,e_ I1 FOR APPXICANT TO FILL IN NEAREST LEGAL ��}} CROSS ST. DESCRIPTION504 L94 !J OWNER BLOCK TRACT MAIL pADDRESS SIZE OF LOT NO OF BLDGS. NOW ON LOT CITY 'C " TEL NO ^ ' OF 9EML%22RVE� BUILDINGS - G DIST NO. I GROUP MAP 11�/ if • P CONTRACTOR .t + f!"1 ADDRESS !t/ CONNECTION DATA CITY ��L �. NO. -�y .... /Z STATION * 4' DEPTH REGISTRATION NO. / �� i 0 COUNTY . 1 N'I -�� .,Z' STATE MA UPPER REFERENCE LOWER ttt�� TYP?!MZECTION LENGTH FROM NO. DESCRIPTION OF WORK FEE Y f CURB- D• P L M L.TO P L L HOUSE SEWER CONNECTING TO PUBLIC SEWER Q $ 3 50 tv HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1 00 CONNECT ADDITIONAL BLDG OR CO. IMP NO. JOB NO _ WORK TO HOUSE SEWER 1 00 ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO.Q6 DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO SEP1IC TANK, SEEPAGE PIT OR _ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT $ 1 00 AUTHORIZATION TOTAL FEE Q REIMBURSEMENT FEE CON- TRACTORTHIS TO CONNECTO THE ABOVE DESCR BEDWITH THEH EREI EXIISTINGAMED DWELLII G APPROVALS DATE INSP CTO R'S SIGNATURE TO THE PUBLIC SEWER Q ` SIGNED THIS_ �2=7_DAY OFti�1 t 1gr NEW HOUSE SEWER OWNER - 0 CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK, SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDG 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 I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR D DISCONNECT PLUG AN LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 AM THE LEGAL OWN! F THE ABO DESCRIBED RESIDENTIAL OPERTY. BACKFILL SEPTIC TANKS❑ __11 .SEEP. PIT(S) [I CESSPOOL Ce SIGNATURE OF PERMITTEE, WILLIAM J. FOX,CouN ENGINEER ATION � p2 0 5"'0." X29 4 4�.5 0 :BY BY— DEPUTY DEPUTY ;BY BY ® DEPUTY 111 EPUTY ORKERS'COMPENSATION DECLARATION l h�rdby•aI'm that leave a'certificate -of consent to self jnsure, OJ G.certlficate'o+.WorVCers4Coirlpensotion Insurance, or 76A642D a teriified copy thereof (Sec 3800, Lab C ) 92-0002 DPW 6/88 APPLICATION FOR PERMIT ' Ppllcy NQ Company Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county,building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY II department LI Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING W STATION DEPTH 'COMPENSATION INSURANCE ADDRESS r \ e (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 LOWER I cert) that In the performance of the work for which this _ NEAREST �a.lw TYPE OF CONNECTION LENGTH FROM p CROSS ST r� "� Y CURB P L ML TOP L permit is Issued,'( shall not employ any person In any manner P C NO so as to become'subject,to the Workers'Compensation laws OWNER CO IMP NO JOB NO Date Applicant ADD RESS TRUNK PERMIT NO ROAD PERMIT NO NOTICE' TO APPLICANT If, after making this Certificate OfCITY TEL NO AFFIDAVIT I 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.BLDGs PERMIT NO 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 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 DOW DISTRICT NO GROUP MAP PROCESSED BY CITY TEL NO u BK PG ❑ I am exempt under Sec of the L A.Co uc NSE NO TATE CLLASS 5O � 0O Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL VA IDATION U HOUSE SEWER CONNECTING TO DATE �.. B & P Code for the following reason PUBLIC SEWER O SEPTIC TANK,SEEPAGE PIT OR -..,•,.-. - PITS AND/OR DRAINFIELD FINAL U Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEMW Signature CONNECT ADDITIONAL BLDG`OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER LL OVERFLOW SEEPAGE PIT,DRAINFIELD z I hereby affirm that I am exempt from the Contractor's License' EXTN,CESSPOOL DRYWELL,MANHOLE Law for the (lowing reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE f s- Ode) , SEWER OR DISPOSAL SYSTEM S ACCT.s j, as owner of the property,or my employees with wages as ., their sole compensation, will do the work and the structure +3307 21.5n Is not Intended or offered for sale (Section 7044, Business " A/ and Professions Code) OWNER1 ITEMSS Permit $ J f •❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE lC5z TOTAL 2 1 _'5 0 / licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER CHECK 21.511 CONSTRUCTION LENDING AGENCY ® C, evil I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit Is a OWNER OR Issued (Sec 3097, CIV C ) - OWNERS AGENT ('��y��y Lender's Name ADDRESS - 000 -0001 12/13/SQ 1 Lender's Address 74U 1 AM 10:Q5 I certify that I have read this application and State that the above Information is correct I agree to comply with all County ordinances an tate laws regulating Plumbing and Sewers, and hereby ut nze r t tives of this County to enter upon the ov e r erty for inspection purposes —1 — Signature of Permittee Date 1 SEE REVERSE FOR EXPLANATORY LANGUAGE 1