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Home My Public Portal About6421 GOLDEN WEST AVE_Sewer__ v �1 APPLICATION FOR PERMIT ■i...O,..S■ DIVISION OF RUIIMMGAMID SAFETY SEWEF;-SEWAGE DISPOSAL Lmv� of I" A gelm FA DIRG r VVM-J. FOX,CouNTY Kmaim um Sol DAv.*TT D.IMPUP7 N,SU1-T OF MU"M9 LITY FOR APPLICANT TO E1Tr qq O ST DR'9CItIPTION LOT M0. OfNER BLOCK TRACT NIL DREM NO. OF BLDG$. SIZE OR LOTPP- NOW ON LOT MY TEL. 1110. U OF B I ING9 DISTRICT N0. QROUP OK MAP coNTRACToe (; (; ft , Q7�" —rL _ PQ-7!7 G ADDRESS �{1j 1�. B AII t A LCOOH DATA CITY El int@ TEL NO. FQ . 8-9405 STATION 1:1 DEPTH REGISTRATIOq NO. 152871 O STATE ■ANHOLY REFERENCE ?PER COUNNo. D�5 RIPTION OF WORK FEE HOUSE SEWER CONNECTING TOY. ? FCT10XP.L LEN.L.GTO P. TH r!LOM CUR Y PUBLIC SEW 3.$0 - H USE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITI NAL BLDG. OR P. . NO. WORK Tb HOUSE SEWER 1.00 CO. IMP. X0. JOL NO. ALTER OR REPAIR-EXISTING BEVER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.lot o 2-S ISCONXECT AND ABANDON SEWER STATE ENCROACHMENT AN-0/OR DISPOSAL STEP 1.00 PERMIT NO. SEPTIC TANK,E PAQE PIt OR ITS AN-0/OR DRAINFIELD 3.00. IRDU}TRIAL CE"POOL-DRYWEI.L A -ROY SPECIAL CONDITIONS ONLY 2.00 CHARGES CONNECTION CHARGE ME OWNER'S PmdiT S 1 00 AUTHOREZAT'ION TOTAL FEY O REIRBUXSEMENT FEE J[fiyj I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELJLJN6 APPROVALS DATE INEPECTOR'S SIGNATURE TO THE PUBLIC $EWER SIGNED THP; AY O 9 NEW HOUSE SEWER g:NER OR CONNECT ADDITIONAL N AGENT ; BUILDING OR WORK LANDETA7TE SEPTIC TANK,SEEP,PIT(5) AND/OR DRAINFIELD EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CE$EPOOL,[� DRYWELL[] ATE THAT THE ABOVE 1B CORRECT AND AGREE TO COMPLY LL COUNTY ORDINAN� AND $TATE LAWS REQULATING ALTER,REPAIR,SEWER OR NG AND SEYIERS. SEWAGE D15PDBAL SYSTEM. ��EEB7 C¢¢ttTIFY YNA,T 1 AM PROPERLY REGISTERED AND/ORQD As1IGQUIRED BY LOS ANGELES COU TY AND STATE OF DISCONNECT PLUG AND RNIA OR THAT 1 THA LEGAL OW OF THE ABOYF ABANDON HOUSE SEWER BED MWIDtiNTIAL PERpACIFILSfi C TANKSSEH-.)•ITS CESSPOOUREA■ _ WILLIAM J.FOX.cg6wTy Y:. G1l xiut VALIDATION E-A.WOOD. Ckum7 PLogo. INsrtC-TOR "1 l - 4.5 APPLICATION .FOR PERMIT 1 nrv781OON OF BU1 �n�,,�r�G� A� �� r�ID � SEWER—SEWAGE .1)ISPOSAL Dopaiftmnt of + Co=t= of Los &W'a s "UILDIR9 /�� JOHN A. I_AMBIE, COUNTY ENGINEER ADDRESS �/ m CABBATT D. GRIFFIN, SUPT OPP BUILDING _LOCALITY FOR APPLICANT TO FIU IN cRo> LEGAt OWNER , DES IPTION LOT X0. MAIL BLOCK TAACT ADDRESS N0.OF BLDGB. SIZE OF LOT X01►0 LOT CITY TEL. NO, USE OF - BUILDINGS DISTRICT N0. GROUP YAP 1 yam' z K PG CONTRACTOR F a L. AQDRESS -eoCOON DATA ' ' col STATION DEPTH CITY NO. NARHOLE REFERENCEUPPER fl STATE LOWER REGISTRATION NO. ❑ COUNTY No, DESCRIPTION OF WORK _ FEE HOUSE SEWER CONNECTING TO TYPE OF CORIiHCTIOR LENGTH FROM PUBLICBEWER e mo Y. CURB P.L. Y.L.TO P.L. SEPTIC TANK,SEEPAGE PIT OR PITS AXD/OR DRAIXFIELD Q $3.00 OVblFLow SEEPAGE P17,DRAINFIELD CO. LMP. X0. OB RO� EATX.,CESSPOOL,DRYWE L MANHOLE 2.60 HOUSQ SITWEa CONNECTING TO' PRIVATE 61PPOSAL SYSTEM Q s 1.00 TRUNK PERMIT X0. ROAD PERMIT NO. CORN ECT ADDITIONAL BLDG.OR STATE ENCROACHYENI WOR TO HOUSE 9EVf Q j 1.00 P IT N0. kLTER,R42-ow ABAXDO HOUSE INDUSTRIAL SEWER OR DI POSAL SYSTEM @ 1.00 •ASTE APPROVA CHARGES CORRECTION CWGE_FEE , AUMOMATION -Tom ra REIMBURSEMENT FES I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN MAXED COX- APPROWUS PATE INSPECTOR'SSIGXATURE TRkCTOR TO CONRECT THE ABOVE DESCRIBED MSTINe DWELLING TO HE PUBLIC SEVER. NE1Y HOUSE SEVER _ SIGNED THIS OF 19 CONNECT ADDITIONAL O0W�NER pR / BUILDING OA WORK _ O1kXER5 AGE_N� �'. SEPTIC TANK,SEEP,P(T(S) DDR AND/OR DRAtXFIELD - I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELLp AND STATE THAT THE ABOVE 1S CORRECT AND AGREE'TO COMPLY W4TH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,R�PA1R,SEWER OR PLUMBING AND SEVERS. SEtAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DCSCQNNgCT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AY T}iE_ LEGAL OWNER OF TWE ABOVR ABANDON HO USEBEWM DESCRIBED RESIDE L PROSE!{TY.- SACKPILLSEPTIC SANKS-D SIOII,ATURE SEEP.PIT(S) ❑ CESSPOOLS I] aE PERYITTE JOHN A. LAMBIE. COUNTY ENGIryESR VAUIDATIOI ROBERT A.WOOD, CHIIIr PLtO. INBP[CTOR I x.1.3 41 .0 n WORKER'COMPENSATION DECLARATIQN �E 802(-80) APPLICATION FOR PERMIT E R M IT 1 hereby at7irm W I have a certificate of consent to self SEWER-SEWAGE DISPOSAL Lnsure, or a certificate of Workers'Compensation Insurance,or 'fl a certified copy thereof(Sec. 3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No.�Oompany ❑ FOR APPLICANT TO FILL IN CONNECTION DATA Certified copy is hereby furnished. ❑ BUILDING �7Ln/ t/� STATION DEPTH Certifled copy IS filed with the county building Inspection ADDRE/S Iz/ A, UPPER p� LOC ALITV MANHOLE REFERENCE LOVER Da Applicant NEAREST TYPE OF CONNECTION L[NOTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CRo// R. Y. CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE r.a. No. OWNER CO. IMP. NO. 10 IS N } /�L'_ / MAIL d Mlz Section need not b0 c�..I��•I,ITr,��la�cIed if the lw/ork irrrohed ADDR SEE TRUNK PERMIT NO. R D PERMIT NO. ^ by the permit Is for one hundred dollars ($100) of less.) _� AP PIDAVIT WwIVEw E�COPD. INSTR.NO. OAT■ C}.{7 CL L. NO. I certify that in the performance of the work for which this L GAL permit In issued, I shall not employ any person in any manner DESCRIPTION LOT No. so as to become subject to the Workers' CompenlLatlon Laws. tls►r. opt ■r. WID NG BLOCK TRACT STATE ENCRO HM[NT LLI Date Applicant No. of ■LPERMIT NO. Da/. (n NOTICE TO APPLICANT: If, after making this.Certiflcate of SIZE OF a LOT NOW ON LOT Z Exemption, you should become subject to the Workers' USE of 4 — Compensation provisions of the Labor Code, you must forth- BUILDINGS CHARGES with comply with such CONNECTION CHARGE FEE p y provisions OC ttlL permit shall be CONTRACTOR deemed revoked. LICENSEDATI CONTRACTORS DECLARATION ADDRKSW/ REIMBUR/[Y[NT F[[ I hereby ■fftrm U that I am licensed under provisions of Chapter DI■rRICT No. GROUP YAP PROCESSED ■Y 9 (commencing with Section 7000) of Division 3 of the Bwl- arl SL. No.�b 3 ■K r• ness and Profpsalons Code, and my license Is in full force and STATE LIC. 0 L effect LICENSE No cLwu N0. DESCRIPTION OF WORK FE[ FINAL License Numb L1c.ClassPw HOUSE■EWER CONNECTING TO DAT[ VALIDATION LIC SEWER , """" ■EPTIc TANK,SEEPAGE IIT ow Contractcy�/��5lmq. " pate g�xy2 PIPS/ORDRwINFIELD �_ FINAL HOUSE■EWER cowNEcnwo To RY . ❑ I am exempt from the licensing requirements as I am / PRIVATE DISPOSAL SYSTEM CONNECT ADDIT70 NAL BLDG.Ow licensed architect or ■ regWered professional engineer WoR ro Hou■E.EWER .� acting In my professional c4pacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,4RMNPIELD ExTNY.,CE■SPOOL,DRWELL,NANH OLE ineu and Profesdoru Code). ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL BY STEN Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I a n exempt from the Contractor's OWNER'S Permit 91 5.6 Q 1 A License Law for the following reason (Section 7031.5, Bust- AUTHORIZATION • TOTAL FEE ness and Professions Code): I HAVE AT THISDATE A CONTRACT WITH THE HERa IN KA ED CON- #10`010 O 1 0 ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED JL&MING DWELLIK■I, u owner of the property, w1h do cite work and the To THE PU■uC SEWER. structure V not Intended or offered for sale (Section Rlan[D THIS DAY OF n 2'Db 1 7,50 7044, Business and Professions Code). OWNER OR OWNERS A.ENT -0 0 0 1:7,506 CONSTRUCTION LENDING AGENCY I hereby affirm that there is ■ construction lending agency ADORE■■ 0'8, 1 'Q1 2._8 2 for the performance of the work for which this permit is issued(Sec. 3097,Ctv.C.). Lender's Name Lender's Address I certify that I have road this application and state that the ■bore Information L correct.I agree to comply with all County ordinance}_and. State laws regulating Plumbing and Sewers, and hereby authorise representatives of this County to enter F upon the above-mentioned property for Inspection purposes. t p r SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pefraittee, Date