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HomeMy Public PortalAbout6033 GOLDEN WEST AVE_Sewer__ 76A642D RM CE 808(REV.6/781 APPLICATION � P P L I C TION F O■ E �T - SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT �N O. GROUP BK MAP PG PRO(CE ED/BY BUILDING �v° I V 7� ADDRESS , VV CONNECTION DAT LOCALITY fir NEAREST STATION DEPTH CROSS ST. UPPER MANHOLE REFERENCE LOWER 0 OWNER TYPE OF CONNECTION LENGTH FROM MAIL Y. CURB P.L. M.L.TO P.L. ADDRESS P.C.NO. CO.IMP.NO. JOB NO. CITY TEL.NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. o AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT G✓� NO.OF SLOGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING U5E OF BUILDINGS STATE ENCROACHMENT PERMIT NO. INDUSTRIAL CONTRACTOR 'f WASTE APPROVAL CHARGES ADDRESS CITY NO. CONNECTION CHARGE FEE STATE i r LIC. REIMBURSEMENT FEE LICENSE NO. CLASS + O NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE,,. HOUSE SEWER CONNECTING TO PUBLIC SEWER Q NEW HOUSE SEWER /_7 SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR DRAINFIELD CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM SEPTIC TANK,SEEP.PIT(S) CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD WORK TO HOUSE SEWER o 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❑ a SEEP.PITISI❑ CESSPOOLS❑ OWNER'S Permit s (J AUTHORIZATION I TOTAL FEE Cid VALIDATION///�� I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ,gyp4 O O 1'i pp SIGNED THIS DAY OF 19_ OWNER OR O OWNERS AGENT �{ O O O O ADDRESS O O o €'r00 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY O O O WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 67 O C O L PLUMBING AND SEWERS, I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF Q 1(,j O 2-Kj O CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AND INTEND TO RE- SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. SIGNATURE OF PERMITTEE 76A642D + ``����� �� 6h CE 808(REV.6/761 ©5 AP P L ciT ISS NV R P IT SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PRO SSED BY BK PG BUILDING ADDRESS UJ ���`-' � '�••�/ CONNECTION DATA LOCALITY NEAREST STATION DEPTH CROSS ST. UPPER LOWER MANHOLEREFERENCE q OWNER icY TYPE OF CONNECTION LENGTH FROM MAIL Y. CURB P.L. M.L.TO P.L. ADDRESS P.C.NO. CO.IMP.NO. JOB NO. CITY TEL.NO. , LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. 3 Q AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT IS NO.OF SLOGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS STATE ENCROACHMENT PERMIT NO. INDUSTRIAL CONTRACTOR m WASTE APPROVAL ADDRESS O o r• ICHARGES ,r CONNECTION CHARGE FEE CITY STATE "- LIC. REIMBURSEMENT FEE o LICENSE NO. CLASS NO. 1 DESCRIPTION OF WORK FEE APPROVALS DATE, INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTIN;TO > { , ,�. f M NEW HOUSE SEWER PUBLIC SEWER / JV1 - Q SEPTIC TANK.SEEPAGE PIT OR ©© PITS AND/OR DRAINFIELD CONNECT ADDITIONAL \/ HOUSE SEWER CONNECTING TO BUILDING OR WORK �L�S PRIVATE DISPOSAL SYSTEM SEPTIC TANK,SEEP,PIT(S) CONNECT ADDITIONAL BLDG.OR l AND/OR DRAINFIELD WORK TO HOUSE SEWER c OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL ❑ DRVWELL❑ 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❑ ©l SEEP.PIT(S)❑ CESSPOOLS❑ OWNER'S Permit s AUTHORIZATION I TOTAL FEE VALIDATION '�,(y��/����[[�� n I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- :)6 A 1 TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. D`C/ � SIGNED THIS DAY OF ig_ C U 10 OWNER OR f OWNERS AGENT p p i 4j•Q O ADDRESS 0 p j ? 00L; I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 0602-80 02!��.$O PLUMBING AND SEWERS. 0 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT'I AM THE LEGAL OWNER OF.AND INTEND TO RE- SIDE IN.THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. SIGNATURE. OF PERMITTEE \ 1