HomeMy Public PortalAbout5638 GRACEWOOD AVE_Sewer__ WFAI;TMENT OF COUNTY ENGIIVEER SEWER-SEWAGE I)IISPOSAL 1
DIVISION OF BUILDING AND SAFETY PER J PLICATION
COUNTY OF LOS ANGELES -
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
APPLICANT O FILL IN LOCALITY
BUILDADDRESS Flti�l-c� EAREST
CROSS ST.
LOCALITY C 1. /LJ DISTRICT NO. SERIAL NO. PERMIT NO. c
NEAREST / tL/ / A _ i I a
CROSS ST.
RECEIVED.BY- Ready for Inspection DATE ISSUED
OWNER
MAILs- / s USE ZONE OCCUPANCY MAP
ADDRESS .�._3 iP �� JWC� �/J(�Q D l (� BK PG
CITY T LNG. V
�_
CONTRACTOR / CO.IMP.NO.
ADDRESSl i ,r JOB.NO.
CITYg5), J �� 1-d)EL.NO-7,e- ;l3 TRUNK PERMIT NO.
/ � COUNTY '
REGISTRATION NO. ROAD PERMIT N0.LEG �--- _._.,.,,•_,.
DESCRIPTION LOT N0. �'� 0� Z 7Q STATE ENCROACHMENT -
PERMIT NO.
BLOCK TRACT,(/ / 34 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT y NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FE
NO. DESCRIPTION OF W R FEE U
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING
PUBLIC SEWER @ $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CO N N Ebf ADDITIONAL BLDG.OR EXPTION`RECORDED
ERR
WORK TO HOUSE SEWER 1.00 N0/ DATE I BY
ALTOREPAIR EXISTING .
___JSEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
---PITS AND/OR DRAINFIELD 2.00 STATION '" - DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I --� MANHOLE REFERENCE
.z /..', -TfPV" LOWER
TYPE OF CONNECTION LENGTH FROM
me llEfm P.L. M.L.TO P.L.
OWNERS PERMIT $
AUTHORIZATION I TOTAL FEE ! Lo -
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THF,�PUBLIC SEWER
Oy
SIGNED THIS-------------•----.-DAY OF.-..... ...-_-.-_ ........ ...19.. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.. .. ..�! ................ _ - _-......... BUILDING OR WORK
� EPTIC TANK,SEEP.PIT(S)
ADDRESS. .._ _ -- ...... �.... ................:'��.. AND/OR DRAINFIELD
I HEREBY ACKNOWLED THAT I HAVE READ THIS APPLI. CESSPOOL[] DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOV>DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKSEl
SIGNATURE `J� .� r�re;� SEEP.PIT(S) CESSPOOLS G.
OF PERMITTEE--------•-- - - - - --........................ w
76AG42D G63 1/53 �j
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of tonsent to self ' ffiDo6t DPW t50 u
insure, or o-certlficate of Workers'Comps
enatlon Insurance, or �2D
o•cerflfied copy thereof (Se<. REIM, Lab C.) APPLICATION FOR PERMIT
Policy No. Company
❑ Certified copy Is hereby furnished. SEWER - SEWAGE DISPOSAL
❑ Certified copy Is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department.
Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ADDFiEBB STATKIN DEPTH
(This section need not be completed if the work Involved by the ,__,uE Rt3TI�� UPPER
permit is for one hundred dollars ($100)or less.) LOGALTTY
FROM
I certify that in the performance of the work for which this LOWCR
NEARQST. Y Of CorCURE URB oN P L M L TLltToO P L
permit Is Issued, 1 shall not employ any person in any manner CL
LEGAL PC NO
so as to become subject to the Workers' Compensation Laws. DEeCRl PTK>N LOT NO. CO LW 40 ice NO
Date Applicant BLOCK TRACT TRUNK PERMI NO ROAD PERM T NO
NOTICE TO APPLICANT: If, after making this Certificate of PAGE PARCEL
AFFIDAVIT wATVER EASEMENT RECORD INSTR NO DATE
Exemption, you should become subject to the Workers' No OFEILDG
Compensation provisions of the Labor code, you must forthwith sag OF LOT NOW ON LOT FWY OR ST YA ENING
comply with such provislons or this permit shall be deemed USE Of
revoked. BUILDINGS STATE ENCROACHAA"
LICENSED CONTRACTORS DECLARATION PERMIT No
I hereby affirm that I am licensed under provisions of Chapter OWN EA
9 (commencing with Section 7000) of Division 3 of the Busi- MAIL
lliOT 33 ,ES
ness and Professions Code, and my license is in full force and A,DDRES3
effect. ary TEL HO. —2 cor+IIECTbN CHARGE tg
License Number Llc.Class PEIMOURSENENT IEE
CONTFIACTOH
Contractor Dat• DLSTRICT NO fROIR A1AP PROCESSED BY
AL)DHE88 Bx PG
❑ 1 am exempt under Sec. of the L.A.Co. _
el
Plumbing Code and/or Sec. of the STATE TELATE �NAL I / D LAcLllei 8 LFCEH8E NO. CLAW DATE LIDATION Z
B. & P. Code for the following reason No. D05CRIPTTDN Or WorTK FEE / O
HXrSE SEWER CONNECTING TO
DIC Fes` A4CT.4
Date PU& SEWER 6Y
TANK SEEPAGE PIT OR
Signature PITS ANO OR DRAT NFIElD 57■
OWNER-BUILDER DECLARATION PRTVA P*P 5O 5Y51t]M TO , 1 ITEMS
PRNA
I hereby affirm that I am exempt from the Contractol"s License OR 90
Law for the following reason (Secton 7031.5, Buisnem and Pro- T� 57. 211
fesalons Code : L IIT.DRAINFIELD .
EXTN.CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR A&.NDON HOUSE "CK 5720
I,as owner of the property,or my employees with wages as SEWER OR DLSPOSAL SYSTEM ��r
their sole compensation, will do the work and the structure ` ■�
Is not intended or offered for sale (Section 7041, Business
and Professions Code).
❑ I, as owner of the property, am exclusively contracting with OWNER'S Permit S 1 ]�
licensed contractors to construct the project (Section 7011,
95
Business and Profeuions Code). AUTHORIZATION TOTAL FEE 3528 1 AM10:05
CONSTRUCTION LE�1&VgG'AGENCY HAVE AT THIS DATE A CONTRACT WTH THF HEREw NAMED CONTRACTCC TO ,
I hereby afflrm tha is d constructlon le n ency CONNECT THE AeovE DESCRIBED EXISTING DWELLING To Trw
IF eLIC%WER
for the performance work for whi I r t is
Issued(Sec. 3097, C C.). �- SIGHED THIS DAY OF 19_
OWER OR
Lender's Name OWNERS AGENT
r
Lender's Address
I certify that I have d thi app cat n and to that the
above Information is correct. I agree to comply with all County
ordlnan ar-Icl a regulating Plumbing and Sewers,
and reby otize representatives of this County to enter
u the above-mentioned proper for in PCctio pur s.
L
re of Permittee Dat I SEE REVERSE FOR EXPLANATORY LANGUAGE