HomeMy Public PortalAbout5600 GRACEWOOD AVE_Sewer__ CE`SUE(BMV.6/79) "" AP IC ION FOR M IT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANC38g BUILDING AND SAFETY
FOR APPLICANT TO FILL IN °ISrR)CT(*0. TI
P M" Roca"°°IN
■UO..DWG 60
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ADDRESS
LOCALITY
CONNECTION DA A
N[ARSSTSTATION
CROSS ST. !J
MANHOLE REFERENCE
OWNER ✓ Q ` O R
TYPE Or CONNCCTFON
PJ_ MJ-T
LJSI'JGTH FROM
KAl- � Y. CURDO P.L '
ADDRESS
P.C.NO.
CO.IMP.NO. JOB NO.
CITY TEL NO.
LEGAL TRUNK PSRMTT NO. ROAD PSRMR NO.
DEECRlTION LOT NO.
AFFIDAVIT I WAMR EASEMENT RECORD.WSTR.NO. DAT11
BLOCK TRACT
NO,OF ELDGS.
Em OF LOT NOW ON LOT HWY.OR ET.WIDENWG
B1
�ONGBTAT7 ENCROACHMENT
PE1tl1 R NO.
LN0USRtlkL
CONTRACTOR WASTEAPPROVAL
ROVAL
ADDRfES CiARG ES
CONNECTION CHARGE FEE
RTA LIC_ REIMBURSEMENT FEE
L�u�t NO. 8 CLASS O
NO. DESCRIPTION OF WORK FEE APPROVALS DATE CTO R`8 810NATU V
HOUSE BEWER CONN[Cnp+o TO
PU■LIC 51SWER ,f f�
NEW HOUSE SEWERSEPTIC TANK,SEEPAGE FIT OR
PTTs AND/OR DRAW FIELD CONNECT L
ADDITIONA
HOUSE SEWER CONNECTING TO SUJLDING OR WORK
PRrVATC DISPOSAL SYSTEM
SEPTIC TAMC e■EL PTTtI)
CONNECT ODDMN.ALUSE0EW BLDG.OR AND/OR DRA1NFI SLID
YVOR1(TO HOUI■S[M/tR
OVERFLOW Sf EPAGS PTT.D FIELD CESSPOOL [:1DRYWRLL❑
KXThL.CESSrOOL DRYWELL,MANHOLE
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SIZWMR OR
S EMIL R OR DISPOSAL SYSTEM SEWAGE D IRPOSAL EYSTB M
DISCONNECT PLUG AND
ABANDON HOUSE"WER
EAGKPLL SSFTK:TANKS❑
Sti P.PITIS)❑ CESS POOLS Ell I
OWNER'S Permit 1
AUTHORIZATION I TOTAL FEE 1 161,16, VALIDATION
I HAVE AT THIR DATE A CONTRACT WTfH THE HEREIN NAMED CON-
TPACTOR TO CONNECT TH¢ADOVC DESCRJEED KXWrLPfG DWELLWG
TO THE PUBLIC SEWER
SIGNED THIS DAY OF. 19_ X81 &T A
OWNER OR
OWNERS AO IRNT �# O 0-0 O 1, 0
ADDRESS p
I H[RDBY ACKNOWI-NDGS THAT I HAVE READ THIS APPLICATION �L O O 1 Q 00
AND
S
TATE THAT THSCMOVE IS CORRECT AND AGREE TO COMPLY p
WITH ALL COUNTY 0RDNCEI
INAAND STATE LAWS REGULATING 1 4 O O
PLUM SLNG AND SEMIERE. ~O O O
LICS NAND HMRSEAS REQUIRED ■Y Y CRIMPY THAT L.QS ANGKLJ>S COUNTY REGLSrKFMD STAJTE OD/ORF ' �J 9.
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.AMID TO RE- E.
SIDE WMgy�pp 1 O,THS ABOVE DESCRIBED R[SIDE ,r /IAL PROP■
SIGNATURE
OF PERM
i KERS'COMPENSATION DECLARATION, r
I heraby Irrh'that I have a certificate of c�nsent to self !,J
Insure,#a ccpdrrtificate of Worker'Compensation Insurance, or II
a certified, opy mpany ' b � I'm' APPLICA71ON FOR PERMIT
Policy iN*
ecIffed copy Is hereby.furnished. SEWER o SEWAGE'DISPOSAL
(fled copy Is filed with the cotinty building Inspection COUNTY OF LOS ANGELES SUIVXNG AND-SAFETY.
depart ent.
Do to Appllcont ,I FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKER$' PLT
COMPENSATION INSURANCE STATION --
(This section need not be completed if the work Involved by the MAN-tOtt R> -� � L�permit Is for one hundred dollar (5100)or less ) TYPE OPCONNecT>oHLax3TH RtoM
I certify that In the performance of the work for which this Y. Cv� P. ML TO P.L
permit Is Is;Ked, I shall not employ any person In any mannerso as to bec me sub ect to the Workers'Com sation Laws. P.C.NO.
p I �^ Ar- co.ww.No. Abe No.
TRUNK PBNAVT NO. ROAD PBtMIT NO.
Date Applicant NOTICE TO APPLICANT: ,If, after making this Certificate of ;qftTEL No. APPwvrr wAtvet EABEMBIT R#CORD.IN+srR.No. DATE
Exemption, you should become subject to the Worker'Compensallon provlslons of the Labor code, you must forthwith LOT NO. iWYoR Sr WVOBNING
comply with such provlslohs or this permit shall be deemedrevoked,. TRACT sTArE B+atoaCrw�rT
LICENSED CONTRACTORS DECLARATION $UTNO.of arms- PBtMIT No.
I hereby affirm that I am licensed under provisions of Chapter LAEOF Now ON LOT
4 (commencing with Section 7000) of Mvlslon 3 of the Bust- BUILDINGS CHARM
nese ant! Professions Code, and my license Is In full force and
effect. y� CONTRACTOR 31 OON CHARGE FEE
-� ME�K7
License NumbeLIc.Class
Contractor .—Da te S ADDRESS
DISTRICT NO. GROUP MAP PROQSMD BY
_ CITY TEL. BK PG v
❑ I am exempt under Secof the LA Co. �� Q. ••• Q S 5-,49 —, Af 5- 0
Plumbing Lode and/or Sec. of the No. DESCRIPTION WORK PEE RNAL r`c ,/
HCOUSE SEWER CONNECTING To DATE VALIDATIIl lu
B. & P. Code for the following reason PUBUC SEWS
PIT OR RNAL .Y7
Date PITA As�D/ DRAPA'LE..D
HOUSE SEWER CONNECTPJG TO 6Y
Slgnature CONNECT ADDrTTONAL BOG.OR y
OWNER-BUILDER DEOAPATfON WORK TO HOUSE SEWBt e b / y
SEEPAGE Pr,DRAIN IED
I hereby affirm that I am exempt from the Contractors License ExTN. MAN"M
Law for the following reason (Secton 7031.5, Bulaness aAd Pro- ALTEtt RE ABS HOLM # 1,0
fesslorn Code): sawBi o 0 0 0
❑ I,as owner of the property,or my employees with wages as I o Io 2 7,5 0
their sole compensation, will do the work and the structure
Is not Jntended or offered for safe (Section 7014, Business ID 5to
o o o 2 7,5 0 '
and Professions Code). OWNER'S Permit f
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE 231 o
licensed contractor to construct the project Sectlon 7044, �'3 a 5
Pr I ( � HAVE AT THIS DATE A CONTRACT w7TM THE FQtEN NAnr® oR TO
Business and Professlons Code). CC"4LCT THE ABOVE DESCRIBE)EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ,
I hereby affirm that Thera Is a construction lending agency SrAM THIS DAY OF 19_
for the performance of the work for which this permit Is OWNER OR
Issued (Sec. 3097, Civ. C.). Q%tAtiS AGENT
ADDRESS
Lenders Ngme
Lenders Addross
I certtfy that I have read this application and state that the
above Informatlon 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 t above-m o e, property f Ion u
11
Signature of Perml M kff%r s FOR DQLA'NATORY LANGUA04