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Home My Public Portal About5642 GRACEWOOD AVE_Sewer__ DEPAIiTMffiNT OF OODNTY >sINGErB SEWER-SEWAGE "BISF4'SAL 1 DIVISION OF BULLDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANG ET, WILLIAM J. FOX, COUNTY ENOIIIt[R BUILDING I ADDRESS S � C FOR APPLICANT TO FILL IN LOCALITY BUILDING -- !� NEAREST ADDRE88 9r CROSS ST. A-iffl LOCALITY DISTRICT NO. SERIAL NO. { J PERMIT NO. .c NEAREST t .J v/ CROSS ST. EIVED BY Riady for Iospmdo■ DATE ISSUED _ OWNER r •(/ATL MAIL US E OCCUPANCY MAP ADDRES8 BK pG CITY TELMO. I;� E�"1 0 — CONTRACTOR / CO.IMP.NO. ADDRESS 4 (J p JOB N0. CITY tY TELNO. J '� gGpD , TRUNK-PERMIT NO. --r---- REGISTRATION N0. O STATE UNTY ROAD PERMIT N0. LEGALSTATE ENCROACHMENT. DESCRIPTION LOT NO.—";'—4r.,C PERMIT NO. BLOCK TRAOT INDUSTRIAL W APPROVAL SIZE OF LOT' NO.OF BLDGS. CHARGE8 �3 NOW ON LOT USE OFC01NM N CHARGE FEE BUILDINGS NO. DESCRIPTION OF WORK FEE REIYBUR8EMH E OUSE S ER OONMEOT NS TO PUBLIO SEWER 9 s L58 RECEIPT NO. DATE BY DON NG - ' PRIVATE DISPOSAL SYSTEM 1.00 0 AbbilioNAL Bl-ba.08 EXCEPTION RE HD, WORK TO HOUSE SEWER Im N O. ATTER 8RRE DATE SEWER OR DISPOSAL SYSTEM 1.00 DISC"NEGT ANDABANDON UWER ANDORDISP08ALSYSTEM 1.00 CONNECTION DATA PITS AND/OR DRAINFIELD R 2A/ STATIONPTH LL 8PENAL Of)NDITIONS ONLY LM RENC[ UPPER LOWER CONNECTION LEND CURB P.L. M.L TO P.L OWNERS PIT $ 00 AUTHORIZATION TOTAL FSE 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTO"SIGNATURE DATE DWELLING TO THE PUBWO SEWER SIGNED THI A OF Iq_ NEW HOUSE SEWER �� .. 7 7, OWNER OR BUILDING ORWORK NECTADDAL OWNERS AGTAN ENT R ADDRE88 SEPTAND/OR DRAIMFIELD IT(S) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL❑ DRYWELL❑ 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 DISP04XL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUS AN AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWEq AND STATE OF CALIFORNIA OR THAT I AY THE LEGAL OWN- ER OF TTI[ ABOVE DESCRIBED RESI [MTI PROPERTY. C 0 AN ❑ BN ATURE f"P.PIT(S)E] CESSPOOLSCl 0 i OF PERIMITTEIr F TdAM A 66S T/U ' — WORKERS' COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self 6A642 DPw si89 7 Insure, or a certificate of Workers' Compensation Insurance, or 6A642D i o certified copy thereof (Sec 3800, lab C.) APPLICATION FOR PERMIT Policy No -Company ❑ Certified copy Is hereby furnishedSEWER - 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' BUILDING COMPENSATION INSURANCE ADDRESS STATION DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST Y CURB P1 M L TO P L permit is Issued, I shall not employ any person in any manner LEGAL PC NO so as to become subject to the Workers' Compensation Laws. DESCRIPTION LOT NO CO IMP NO JOB NO Date Applicant BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT If, after makm this Certif tate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE g MAP BOOK PAGE PARCEL Exemption, you should become subject too the WorkersNO.OF BLDGS Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL gooaESs i CHARGES ness and Professions Code, and my,license is in full force and effect. CITY TEL NO - CONNECTION CHARGE FEE License Number Lic.Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED Bl } ADDRESS SK PG o ❑ I am exempt under Sec of the L.A. Co, CITY ry TEL NO _ Plumbing Code and%or Sec of the STATE LIC F NAL LICENSE NO CLASS DATE LI1(A DATION _ B. 8 P Code for the following reason NO. DESCRIPTION OF WORK FEE j� R HOUSE SEACpWER CONNECTING TO FINAL Q Date PUBLIC SEWER BY r t 2 SEPTIC TANK SEEPAGE PIT OR d Signature PITS AND OR DRAINFIELD LT 2 OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TOr�+ LU PRIVATE DISPOSAL SYSTEM '� r'.. `4� f•' I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- ' WORK TO HOUSE SEWER 'i�'�• ,t,Y� tA.�•^� OVERFLOW SEEPAGE PIT DRAINFIELD Pro- fessions Code): ExTN CESSPOOL DRYWELL.MANHOLE 1, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE4eF� (' SEWER OR DISPOSAL SYSTEM their sole compensation, will do the work and the structure � ,dl:; ' is not intended or offered for sale (Section 7044, Business and Professions Code). ❑ 1, as owner of the property, am exclusively contracting with OWNERS Permit $ licensed contractors to construct the project (Section 7044, Business and Professions Code). AUTHORIZATION TOTAL FEE CONSTRUCTION LENDING AGENCY i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Poo hereby affirm that-there is a construction lending,agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER for the performance of`i.be work for whicb,lhis permit Is issued Sec. 3097, Civ C .. SIGNED THIS DAY OF v OWNER OR Lender's NameOWNERS AGENT Lender's Address ✓ ADDRESS I certify that I have ceod this application and crate that the above information is correct. I agree to comply with all County ordinances and S.1Wd'1aws regulating Plumbing and Sewers, and hereby adforize representatives of this County to enter upon the above-mentioned prope!Jy,for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE