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Home My Public Portal About5621 GRACEWOOD AVE_Sewer__ DEPAILTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER BUILDING h" ADDRESS ,'' V I FQR APPLICAUIT FILL IN LOCALITY e �, BUILDING EAREST ' s ADDRESS . 1 CL' CROSS ST. LOCALIT T DISTRICT NO. A SERIAL NO. PERMIT NO.NEARE C CROSS ST. J RECEIVED.BY Ready for Inspection DATE ISSUED OWNER }-r..�L` S' MAIL J7 ADDRESS USE ZONE OCCUPANCY i MAP 'BK PG CITY TELAO. CONTRACTOR `Cfl` Z�b Al�`Y' •\ ��r CO.IMP.N0. ADDRESS rr r -G l./L .f✓/ l:2 JOB N0. CITY 154W -,ajQ`��NO. �^ �X,�C l-�-L� /7Eo. g TRUNK PERMIT N0. f/^ IV F7 LJ STATE 0. REGISTRATION Nl�f(� COUNTY ROAD PERMIT N0. LEGAL DESCRIPTION LOT N0. STATE ENCROACHMENT- PERMIT NO. BLOCK TRACT !/C:/ -J INDUSTRIAL _ WASTE APPROVAL (�^ X NO.OF BLDGS. SIZE OF LOT ^L NOW ON LOT CHARGFB' USE OF ! BUILDINGS WAZ44- /,<� -` , /�6 CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO // REIMBURSEMENT FEE PUBLIC SEWER (g! $ 3.50 V, RECEIPT l J. I ATE I BY HOUSE SEWER CONNECTING TO _ PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXEPTIONCORDED WORK TO HOUSE SEWER 1:00 ALTER OR REPAIR EXISTING NQ I DATEI BY SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER,AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR. PITS AND/OR DRAINFIELD 2.00STATION _ DEPTH L :U/ CESSPOOLDRYWELL _�' SPECIAL CONDITIONS-ONLY - 2.00 ,.'•�AEFERENpE.- ' VPPE ` ; -tllY6R TYPE OF CONNECTION Y LENGTH FROM OWNERS PERMIT $ 1 00 x'" `''� t P•L. M.L.TO P.L. AUTHORIZATION I TOTAL FEE C1 F HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE D CRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER kil S*NED THIS.....J_J........DAY OF---------- ----- v_--------__19..._ NEW HOUSE SEWER �� a l ✓-v DDWI W ER OR �oa- i.— CONNECT ADDITIONAL OW RS AGENT) l ._ ___..._.._.............. ..__._ BUILDING OR WORK SEPTIC AD1)RESS31�_,-/.._. ,$y_,� .. t ' AND/OR DRAINFIELD PIT(S) CAI HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL I] DRYWELL F]TION AND STATE THAT THE ABOVE IS CORRECT AND AGREE _ TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM _ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR#THgT 1 AM THE LEGAL SOWN- ABANDON HOUSE SEWER ER OF THE ABOVE_4s RE ENTIALPR P�T / BACKFILL SEPTIC TANKS E SIGNATURE . � SEEP.PIT(S)E] CESSPOOLS � - i . ,. OF PERMITTEE._.___-___.._..__'...- ' — --------------._�_ . 76A642D 663 1/53 WORK]ERS'OO& ENSATFON DECLARATION I hereby affirm that I-have a certfflcate of.consent to self insure, or a certiflowe of Workers'Compensation Insurance, or 7�� Ro ` mpany �' �Nt� �°0ej '�' APPLICATION FOR PERMIT Lul F-.certtfiee copy Is hereby fumishad..: - SEWER - SEWAGE DISPOSAL C«tlfied copy Is filed wit the c9unETY ty 6u Iding Inspection COUNTY OF LOS ANGELES BUILDING AND SAF rtment. Dare Ircant r FOR APPLICANT TO FILL IN CONNECTION DATA GTE OF CERTIFICOJtAPENSATI t INSURANCES SAH (This section need not be completed If the Work Involved by the LOCALITY � MANIHCLE REFa� uPPei permit Is for one hundred dollars ($100)or less.) TYPE I certify that In the performance of the work for whish this � �, Y � LENGTH FROM permit h Issued, I shall not employ any person In any,manner r CURD P.L. M L TO P.L so as to become subject t6 the Workers' Compensation taws_ Pec No. 1 pe owNER co.6-AP.No. roe No. Date ApplKant MAR RRfSs Pti'I TRUNK PERIWT NO. Raw PERMIT NO. NOTICE TO APPLICANT: If, after making this Certificate of � TEL.NO. APF3wvIT wAtvsT E�siHBrr rfOORD.rrSTR.NO. DATE Exemptl9n, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR S WIDENING , comply with such provisions or this permit shall be deemed revoked. BLOOC TRACT STATE ENCROACHAAENPT LICI=NSED CONTRACTORS DECLARATIONNo.OF 1s1DGS PERMIT No. I hereby affirm that I am licensed under provisions of Chapter SIZEOFLOT NOW ON LOT USE OF 9 (commenclRg with Seaton 7000) of Division 3 of the Busk BUILDRJGS GL CHARGES nen and Professions Code, and my license Is In full force and effect. CONTRACTOR K CONNECTION CHARGE FEE PG Llce�rme Number �Llc.Close +� ADoaEss FEE � C6f�ttaCTOr" TEL.N..`T-1!�'�-�tIs 3"c? /� DMTRCT NO., /GBK AP 8 ROUP MDV (7TV `/ ❑ I am exempt under Sec. of the LA.Co. STLI�r10 a S 5( O Plumbing'Code and/or Sec. of the No. DESCRIPTION OF WORK FEE PINAL ow HOUSE Sty CONINK INa TO DATE VALIDATI N 1sTTuu B. b P. Code for the following reason PUBLIC SEWER PIT OR F#MAL PRS AtA/Oit DRA1NtItSD Date HOUSE SEWER C XPa;7TRJC TO BY PRTVAfllfA Signature CONti{T oorrlOr.v,1 eLDQ,_OR OWNER-BUILDER DECLARATION WORK TO SL. RFL SEEPAGE PIT NRRD I hereby a-fflrm that I am exempt from the Contractor's License EurN. CESSPOCX, MA 4HOLE Law for the following reason (Sector 7031.5, Buis-non and Pro- A1TFR REPAIR OR AaANDON HOUSE fessions Code)-, Sewf3t OR DISP'O'SAL SYSTEM ❑ I,as owner of the property,or my employees with wages as 2 4 2 Q 0 A their sole compensation, will do the work and the structure '#!Q 0.0 o,l' 0 Is not Intended or offered for sale (Section 7064, Busess inpermit f and Profusions Code). OWNER'S AUTHORIZATION ° - 21.50 E] 1,as owner of the property,am exclusively contracting with TOTAL FEE C licensed contractors to cohstTuct the project (Section 706", 1 HAVE AT THIS DATE A CONTRACT WITH THE HUMN 5 CONTRACTOR NiAh1®CCTOR TO 'D 2.1' 0 6 Business and Profenlons Code). CONNECT TYE ABOVE DESCRAED DTSTNG DWT1U NG TO THE".UC SEWER. 1 CONSTRUCTION LENDING AGENCY. Q •1 9+$6 I hereby affirm that there is a construction lending agency S1G►ED THIS DAY OF 19_ , for the performante of the work for which this permit Is OW41Z OR Inuc.gd (Se3097, Clv. C).. OWNERS AGe14T ' hh ADDRESS Lender's Name l 1 1 Lender's Addren I certify that 1.have read this appllcatton and state that thq above Informatlon Is correct. I ogr"to comply with all County ordinances and State laws regulating PlumblrTg and Sewers, and hereby Authorize representatives of this County to enter upaLn tho above-mentioned property for Inspection purpose& SP nature of Pertnittee Date . SH WVRfit POR EMANATORY UVXWA0!