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Home My Public Portal About6129-6131 GOLDEN WEST AVE_Sewer__ c ,0_B2 76AG42 D APPLICATION FOR PERM 78A 84 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEARE `O JOHN A. LAMBIE, County Engineer l WILLIAM A. JENSEN, Sup't of Building FOR APPLICANT TO FILL IN LEGAL DESCRIPTION LOT NO O �Z MAIL /lC� BLOCK ^ TRACT , ADDRESS • (. NO OF BLD GEr SIZE OF LOT W ON LOT CI TEL NO USE OF DISTRICT O GROUP MAP PROCESS Y BUILDINGS / BK PG 60TFFRACTOR ADDRESS CONNECTION D TA STATION DEPTH CIT TEL NO r IH STATE MANHOLE REFERENCE _ PPER REGISTRA ON NO L� COUNTY S NO DESCRIPTION OF WORK FEE TYPE OFC TION ' LENGT ROM d HOUSE SEWER CONNECTING TO Y CURB P L M L T P LO PUBLIC SEWER $5 00 SEPTIC TANK SEEPAGE PIT OR P C NO V PITS AN OR DRAINFIELD @ $10 00 CO IMP NO JOB NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT O PRIVATE DISPOSAL SYSTEM @ $300 F CONNECT ADDITIONAL BLDG OR AFFIDAVIT I IN IVEx I EASEMENT RECORD INSTR N6 DATE IV WORK TO HOUSE SEWER @ $300 d OVERFLOW SEEPAGE PIT,DRAINFIELD H EXTN C ESSPOOL,DRYWELL MANHOLE @ $500 z ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES LRESIDE WNERS PERMIT S 2 00 CONNECTION CHARGE FEE HORIZATION TOTAL FEE VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING HE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE NED THIS DAY OF 19_ ER OR NEW HOUSE SEWER ERS AGENT CONNECT ADDITIONAL BUILDING OR WORK RESS SEPTIC TANK SEEP,PIT(S) EREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ALL COUNTY ORDINANCES AND STATE LAWS REGULATING BING AND SEWERS CESSPOOL ❑ DRYWELL ❑ EREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR NSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM FORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND DE IN, THE ABOV DESCRIB E TI PROPERTY ABANDON HOUSE SEWER ATURE BACKFILL SEPTIC TANKS PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD CK M O CASH SUPERVISING MECHANICAL ENGINEER UICo3 8 6 4I'D DEC 26 1 0 D 'x.00 WORKERS'COMPENSATION DECLARATION D CE 808 (2-80) APPLICATION FOR PERMIT CE 808 1 hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or ` a certified copy thereof(Sec. 3800ab.. C.)) I - COUNTY OF LOS ANGELES C_ BUILDING AND SAFETY Policy No. Company_i Cg :r I � we $!10563j FOR APPLICANT TO FILL IN CONNECTION DATA ❑ C we copy Is h reby furnisP - ' BUILDING ' STATION DEPTH ❑ Certified copy is filed with tnty building inspection wDOREss UPPER d artm t. f/ LOCALITY7mm e— MANHOLE REFERENCE v,Da 1& icant LOWER /` NEAREST � TYPE OF CONNECTION LENGTH FROM �'" CERTIFICATE OF EXEM ION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P,L. COMPENSATION INSURANCE P.C. No. .OWNER CO. IMP. NO. JOB NO. MAIL (This section need not be completed if the work Involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. by the permit is for one hundred dollars ($100) or less.) a CITY .PLe C4YE NO. AFFIDAVIT I WAIVER EASEMENT RECORD, INSTR, NO. DATE O I certify that in the performance of the work for which this, LEGAL U permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. Q BLOCK 'Ll TRACT STATE ENCROACHMENT Date Applicant Y OF BLDGS. PERMI NO. - (� NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF Lo —�� 1G NOW ON LOT Zee, �� . -2 O� a Exemption, you should become subject to the Workers' US OF �� CHARGES Z Compensation provisions of the Labor Code, you must forth- With comply with such provisions or this permit shall be CONTRACT �. CONNECTION CHARGE FEE deemed revoked. LICENSED CONTRACTORS DECLARATION ADDRESS REIMBURSEMENT FEE I hereby affirm that I am licensed under provisions of Chapter e— DISTRICT NO. GROUP MAP PROCESSED BY 9 (commencing with Section 7000) of Division 3 of the Busi- CITY TEL. NO. r BKSTATE ness and Professions Code, and my license is in full force and LIC ENSE No. LILASS J effect. /� � NO. DESCRIP ION OF W R FEE VALIDATION �+ FINAL HOUSE SEWER CONNECTING TO �7 License Number Lie. Class L� PUBLIC SEWER DATE 7-7- Contract,, -��- (� FVC- 2 SEPTIC TANK,SEEPAGE PIT OR - r I�16 r PITS AND/OR DRAINFIELD FINAL Contracto Date�_ HOUSE SEWER CONNECTING TO BY ❑ PRIVATE DISPOSAL SYSTEM P I e e o he licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR cen d architect Or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,GRAINFIELD iness and Professions Code). _ EXTN.,CESSPOOL,DRYWELL, MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lie.or Reg.No. Date Yd . HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit f License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): q7 /1 4 R I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- z .6 2 2A ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I, as owner of the property, will do the work and the TO THE PUBLIC SEWER. structure is not intended or offered for sale (Section SIGNED THIS DAY OF 19 # 0 0 0 0 1 0 7044, Business and Professions Code). OWNER DR OWNERS AG ENT 2;D D1 .7.50 CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there is a construction lending agency o 0 0 3.501 for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). 6 2 8-82 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-mentioned ropert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE S' nature 4er-it Date