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HomeMy Public PortalAbout6019 GOLDEN WEST AVE_Sewer__ 76 6-420 -54 e49�PLI CATION ■ Oi ■ ■ E � ■MI ■ .i 5&E-663 12.54 DIVISION OF BUILDING AND SAFETY- SEWER-SEWAGE DISPOSAL Department of County Engineer MMMM County of LOS Angeles BUILDING WM. J. FOX, COUNTY ENGINEER 4ADDRESS CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY ` FOR APPLICANT TO FILL IN NEAREST CROSS ST. LEGAL 6!14 ,/ DESCRIPTION LOT NO 'fit�g �S ' �j�•- OWNER 0 BLOCK TRACT MAIL ADDRESS Th SIZE OF LOT S` N0. OF BLDGS. OW ON LOT CITY INO., USE OF BUILDINGS = DISTT� NO. I GR I MAP BK PG CONTRACTOR ADDRESS1'17a461 CONNECTION DATA / V CITY TEL. NO 'l STATION DEPTH P9".x• ❑ STATE MANHOLE REFERENCE REGISTRATION NO. - ❑ COUNTY UPPER LOWER TYPE OF CONNECTION LENGTH FROM No. DESCRIPTION OF WORK FEE Y CUR P L M.L.TO P L HOUSE SEWER CONNECTING TO r. -Ir- � PUBLIC SEWER - @ $ 3 50 r HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 100 CONNECT ADDITIONAL BLDG. OR CO, IMP. NO, JOB. N0. WORK TO HOUSE SEWER 1 00 00 ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT N0. ROAD PERMIT NO. DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR.,DISPOSAL SYSTEM 1 00 PERMIT NO SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR�DRAINFIELD 2 00 INDUSTRIAL - 'CESSPOOL- DRYWELL WASTE APPROVAL 'SPECIAL CONDITIONS ONLY 2 00 CHARGES CONNECTION CHARGE FEE OWNERS PERMIT $ 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE TRACTORHAVE T TO DATE CONNECT THECTED ABOVEWITH THE DESCP BEDH EXISTINGMED DWELL G APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER SIGNED THISNzr— DAY OF 19tz4077'� NEW HOUSE SEWER' OWNER OR CONNECT ADDITIONAL A gr�B OWNERS G/E�NT BUILDING OR WORK //r] ADDRESS �' - SEPTIC TANK, SEEP, PIT(S) - AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 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 I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 AM THE LEGAL OWNER'-OF THE ABOVE DESCRIBED RESIDENTIA PROPERTY. BACKFILL SEPTIC TANKS❑ SEEP. PIT(S) ❑ CESSPOOLS❑ ' SIGNATURE - OF PERMV WILLIAM J. FOX,COUNTY ENGINEER vALIDATION By L, �8 7B8 9 Lr JMJ 3 4 2.00 to m DEPUTY PUTY c .BY BY .-,1.® DEPUTY DEPUTY WORI4ERS'CONjPENSATION DECLARATION A I he- ' y affix�thok-I,4ve a certificate of consent to.'self° �I inSure, or a cer ttdie'of'Workers'Compensation Insurance, Or 76A642D Ls, a certified copthereof (Sec 3800' Lab C ) CE 808(REV 8,811 , :. APPLICATION. FOR .PERMIT, PERMIT, *� Policy No ompany .� ©s - _ - -' - - ® 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 •JF_ Applicant — 4L0 FOR APPLICANT TO FILL IN CONNECTION DATA { --I CERTIFICATE OF EXEMPTION FROM WORKER 'BUILDING COMPENSATION'INSURANCE ' ADDRESS / 15L 7 : STATION DEPTH (This section need not be completed if the work invo ed by the LOCALITY t MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100),or less ) '• - ° LOWER NEAREST .a,�- TYPE OF CONNECTION LENGTH FROM I�ceftify�that in_'the performance of the work-for which this CROSS ST �fl(/ Y CURB. P L MC To P L.. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws OWNER CO IMP NO •- JOB NO MAIL' TRUNK PERMIT NO ROAD PERMIT'NO Date Applicant ADDRESS NOTICE' TO APPLICANT If, after rr,akin this Certificate Of ^ L AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g CITY V 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 BLDGSSIZE OF LOT S >04117 NOW ON LOT PERMIT NO z - ' > I hereby affi"rm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000),of Division 3 of the Busi- BUILDINGS P CHARGES ness and Professions Code, and my license is in full force and effect CONTRACTOR — CONNECTION CHARGE FEE- License Number - Lic Class /?Q ADDRESS REIMBURSEMENT FEE O Contractor L�–•T1"r�11� Date�'. � � CITY � •! v� 6 DISTRICT NO GROUP MAP PR ESSED V El I am exem t under Sec of the LiA Co STATE uC BK PG Z p LICENSE NO CLASSY O Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL V HOUSE SEWER CONNECTING TOLu - ' , d B & P Code for-the following reason _ PUBLIC SEWER DATE)Zia SEPTIC TANK,SEEPAGE PIT OR °VALID ON a -( z 'PITS AND/OR DRAINFIELD FIN ' Date HOUSE SEWER CONNECTING TO BY - ,1.n n A ' PRIVATE DISPOSAL SYSTEM - - • 9 9 •Y Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION WORK To HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD ► - '# O,o o o.�� O I hereby affirm that I am exempt from the COnirOCtOr'S License EXTN,CESSPOOL,DRYWELL,MANHOLE -Law for the following reason (Secton 7031 5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ­62A,5fessions Code) I SEWER OR DISPOSAL SYSTEM I`f O- ❑ l;as^owner of the property,or my employees with wages as ,o o `e.21 5 0 v their sole compensation, will do the-work'ond the structure is'not intended or offered for sole'Section 7044, Business' . and Professions Code) ( OWNER'SPermit $ � 9)1'S`,8 7 m exclusively contractmg-with 5 AUTHORIZATION ,TOTAL FEE I,as'owner of the property, a licensed contractors to construct the project (Section 7044, 1 HAVE-AT THIS DATE,A CONTRACT WITH THE HEREIN NAMED`CONTRACTOR TO Business and Professi Oris Code) CONNECT THE ABOVE DESCRIBED EXISTING.DWELLING TO THE PUBLIC SEWER CONSTRUCTION'LENDING AGENCY ' I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19= ' 'OWNERIOR ` for the performance ,of the work for which, this permit Is OWNERS AGENT_ issued (Sec 3097, Civ C ) ADDRESS Lender's Name Lender's Address I certify, that I have-read this application and state that the # above Information is correct l.agree'to comply with all County g ; ordiridnces,and State laws regulating'Plumbing and Sewers,' and hereby-outhonie representatives of this County to enter upon The above-mentioned property for inspection purposes l Sign Lure of PerVitte Date" f SEE REVERSE FOR EXPLANATORY LANGUAGE