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HomeMy Public PortalAbout10766 GRAND AVE_Sewer__ CLOG"-•[ APPLICATION FOR PERMIT 7eAe4aD COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION ■UILDINo JOHN A. LAMBIE, CouNTY ENGINEER ADPR[SS d 1 COLEMAN W. JENKINS. SUPT. OF' BUILDING i LOCAL" KKARUT FOR APPLICW TO FILL IN CROS, fT. SCRIPTION T LEGAL DELONO. OWII ER MAIL d - Ire 7' BLOCK TRACT � ADDRESS �/r Intl[ NO. OF SLOGS. SIZE OF LOTAjj�k NOW ON LOT orcITY V TEL NO. U/[ OF DISTIIICT O GROUP MAP P BY BUILDING• doqro CONTRACTOR re e, ,&4 ADDRESS C CT-ION DATA STATION DEPTH CITY w TEL N0. STATE w - MANHOLE R[F6IRE NCE URFER LICENSE NO, 11 LOWER No. DESCRIPTION OF WORK' FE[ lyPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO Y. CUR■ M.L TO P.L. a E PUBLIC SEWER 0 if.00 O • T PIC TANK.f O[P P.C.NO, PITS AND/OR DRAINFIELD $10.00 CO.IMP.NO. JOB NO� V HOU• •EWER CONNECTING TO TRUNK PERMIT NO, WOAD PERMIT NO. tie PRIVATE DISPOSAL SYSTEM 57.00 O CONNECT ADDITIONAL BLDG.OR l}, Lugx T I RECORD.H4STR.NO. DATE r WORK TO HOUSE SEWER $7.00 `LLJJ OVERFLOW SEEPAGE PIT.DIIAINFIELD d R)TN..C[S■POOL.DRYW ELL MAN H OL[0 $5.00 U) ALTER,REPAIR OR AILANDON HOUSE HWY.OR•T.WIDENING Z SEWER OR DISPOSAL SYSTEM 41 7.00 STATE FNCROACHMXPCr PERMIT NO. INDUSTRIAL WASTI APPROVAL OWNER'S PEHMTf s x 00 CHARGES C AUTHORIZATION rorAl. FEE ONN[CTIQN CHARGE FEE I HAVE AT THISDATE A CONTRACT WITH TH[ HEREIN NAMED COH- RE)MSURSEMENT FEE TRACTOR TO Co NN[CT TH[ ABOVE DESCRIS[D EXISTING DWELLING TO THE PUBLIC SEWER. A OVAT 4 DAT= INSP R'S DIG NATU R[ SIGNED THIS-DAY O 12_ OWNER ORHW HOUSE SEWER OWNERS AGE1�2 HEW ADDRIbNAL ADDRUf r BUILDING OR WORK SEPTIC TANK.SEEP,PIT(f) I H[R[SY ACKNOWLIDG[ THAT I HAVE RG TNI■ APPLICATION ../OR DRAINFI6LD AND STAT[ THAT TH[ AfQVE IB CORRECT AN AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND fTATE LAW/ REGULATING �If1Pb OL El DRYW[LL [IPLU Me ING AND SEWERS. I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALT".REPAIR.SEWER OR LICENSED A• REQUIRED BY LOS ANGLES COUNTY AND STATE OF /[WAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEO HER OF. AND INTEND TO DISCONNECT PLUG AND R ESI D[ IN. THE ABOVE D RI■ RESIDENTIAL PROPERTY. ABANDON HOUS[7[WER SIGNATURE OF PER MTTTE[ SAC�KFILL•EPbIC TANKS EM LEEP.PIT(/) U CWPOOLJ VALM.0. 7�� � JACK R. RLLLLN CK. Y.O. UPERVI$INQ MECHANICAL ENGINEER JQ7324�8 IM1910 D 7l()0" a WORKERS'COMPENSATION DECLARATKON I hereby*affirm that Io �ef ��crtsTn ot to self Jr�ure, or a certffk4te'a&kens n Insurance, o[ nAmw cop+kl7heredf(Sec. 39W, Lab C- ' a-ODM COW VW APPLICATION FOR PERMIT Policy //No._'Company SEWER _ SEWAGE DISPOSAL 11�ttfied 4opy h hereby fumished. ❑ Certified copy is flied with the county boflding Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Ll Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF BgAI TfON FROM WORKERS' COMPENSATIQN INSURANCE AD6RESS7r, tJ�'� O STATION DEPTH (Thls section need not be completed if the work Involved by thetocxrn MAW1olr ram UPM er pmit Is for one hundred dollars (;100)or less ) NEAREST TYPe OF �PTM t1ZOA1 I corlify that In thence of the work for which this CROSSl� � Y. � Ck . P.L ML TO P.0-_ permit Is Lwued, I shall not employ arty person In any roonner so as to become subject to the Workers'Compensation !"6-cx t5L�.f/ Co.kw.NO. P.C.� ,}i� DTF / Tktw Pez"T No. WAD PBLWT NO: /y Date Appllcont' p NQTKE TO APPUCAW: If, after Ing this 'Certtftoote of CITY 72; �� ��'- AFFDAVrf wAN61 EASEMENT ._Rs?coRD.iNs7R.NO. DAR Exemption, you' should. become become subject to the Workers' .. L� 1 Compgnsatlon provislan;of the Labor code, yop myst forthwith Dg�K)N LOT NQ. comply with such provWont or this permit shalr be downed - _ Hl - ST.wbeaNG revoked. BLOCK TRACT STAR BJGRQACFVAENT " LICENSED CONTRACTORS DECLARATION No.bretDod - ' I hereby affirm that I-am licensed under provisions of Chapter SIM ROT Now oN l 9 tcommenclng.with Sectlon 7000) of Division 3 of the Busl- Lmi OF l35 CHARGES non and Professions Code, and my license Is In•full fora and effect_ CO-T� CONNtCTK N CHARGE PEE License Number �!Class le—Y yS�7w ADDRM z Contractor©` ' �d�f Cm Ta.No. E PG ❑ 1 am exempt under Sec of the LA.Co. u No. g 5K ass `� / O PlumNnp Code and/or Sec. of the No. RTtOtNOF WORK ig t ".^ U' H�ss K�et CON ECTM TO DAJJV) IV - VAS M B. b P. Code for the following reason % PIT M Date Fy HOJR f!•wER Q(NN TO Signature CONNECT ADDrnCNAL BLDG.OR 7� OWNER-BUILDER DEaARATION WORK TO Hous swat . Kn I hereby Affirm that I am exempt from the Contractor's Llcomw D(TN CESSOODL, MAr�rOtE i Law for the following reason (Secton 7031.5, Buis-nests and Pso- ALT6t ETON House fesslons Code): gw�t 1,as own er of the property,or my employees with wages as ACCT. e1r sots compensatlbn, will do the work and the structurb v. 1t1� Is not Intended or of efied for sale (Section 7W4, Business T30— +7 - 21■50 and Professions CodeX OWNER'S Permit $ 1 ITERS ElI,as owner Qf Rho-property,am exclLrslvely cdnfractlnq with iA►UTFFOR1ZA770M TOTAL FEE licensed contractors to construct thb project (Section 7044,' I HAVE AT Tis DAR A MrtTII tT� F6t91 NAMED TO - _ _._.____.TOT& - `2 1. 50 Business and Professions Code). CONTeCr t Aec/NE Da �oasTU1K3 Dw�1Mo To THE Pt IRK - r� CONSTRUCTION LENDING AGENCY , OECK 21.50 I hereby affirm that there Is a construction lending agencyGNM IS YOF 1 .uLr for the performance of the work for which this permit Is owrM AoelT 00 Issued (Sec. 3097, C1v. C_) Ir Aooress �y�y-yt , Lenders Name t�'M1 10/3V89 Lender's Address- .8=27 I .certify that I have read this oppllcatton and state that The 6466 1 Ali above Information Is.correct. I agree to comply with all County ordinances and State laws regulating Plumbing and-Sewers, and heralbyauthorize represen.Wives of this County to enter u eve-Mentioned Ion purposes. Slq re of Pbrmlttee SE ltt>nr@ KW ManAMATO[Y VOOGUAGi••