HomeMy Public PortalAbout10046 GREEN ST_Sewer__ aa"tx7 11-IID APPLICATION FOR PERMIT 1
i i 40 '
DIVffiION OF B4I.DMG AND $AF'ETY SEWER—SEWAGE D i S POSA L
of Co-mt7 Eap'fasslr
. Co=tl of Los Anuid s BUILDING
JOHN A. LAMBIE, CouN-rY ENOINEER ADDRESS
CABBA77 D. GRIFFIN, aVP T 0�19u1t_bINa LOCALITY ,'j'�, —'
FOR APPLIGAN'f ZO IN cRosD�aT. • • Baldwin�Ave.
LEGAL
DES CRIFTlopI Lor X0. Qw„� L. - �. �t`i•Q'hig
TAIL
BLACK TRACT I �2”�oO ADDRESS e .
NO. OF BLDGS. CITY TEL.AO
SIZE bF LOT - NOW ON LOT
USE OF
.BUIL.DINGS DI37RICT NO GROUP BK YAP .
PG
CONTRACTOR N. H'a ehanan
ADDRESS 132-44 E. Ramona OTT
� 1 STAT CON DATA
cITYBald�vin Park TELL No. — I` 213- DEPTH
YAC HO ERENCE UPPER
REWsTRATION No. 121537 STATE LOWER
p COUNTY
NO. DESCRIMON OF WORK FEE
HOUSE SEWER COMMECT1140 TO 'f1P><OF CONE N LE FROM
PUBLIC SEWER 3.50 Y. CURB .L. 0 P.L.
SEPTIC TM ,SPEPAGE PIT 0
P D/
ANOR DRAINFIELD 9 5.00
VERFLOW SEEPAGE PIT.DRAINFIELU rr�� CO. ITP.NO JOB HO. `
EXTN.,CEBSPO L DRYWELL MANHOLE 2.00 4 OO `
HOU EWER CONNECTING TO
PRIVATE DISPOSAL,SYSTEM Q 41.60 TRUNK PERMIT ROAD P lT NO.
CONNECT AQDFTI NAL PLDQ.OR STATEE■ CHYENT
WO8K TO 0 sE solp :1.00
PERMIT
��LT�R.RI PAIR OR AB!�NDOIry HOUSE IVDU IAL
S�SVHFI OR DIdPOSAL SYSTEM" 1.00 q PROVAL '
—Existing steres CHARGED
CONNECTION CHARGE FEE
OWNER'S PE MT s o0
AOTHOBTLATION I TOTAL FM
31
00 REIMBURSEMENT FEE
I HAVE AT THISDATE A CO CT WITH THE HEREIN'NMIED CON- APPROVALS DATE INSPFCTOR'SSIGNATQRE
TRACTOR TO CONNECT THE ABO DSDCRIBED MSTING PrWFLLINB
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THOS nAY OF 19 CONNECT ADDITIONAL
OWNER OR 1 BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIt(S)
ADDRESS MD/OR DRAINFIELD '
I HEREBY ACKNOWLEDGE TjtAT I HAVE REAb THIS APPLICATION
AMD (TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY C1a:1$F06L bRYWELL❑
WITH AtG COUNTY ORDINANCES AND STATE LAWS REGULATING ALTM REPAIR,HEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED MD/Oft
LIC4MSED AS REQUIRE[) BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAI' 1 AN DT' O LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REST TI PROPEBACKI'14�L GEPTIC TANKS❑
SIGNATUAS SEEP.PIT(9) El CESSPOOLS El
OF PERMIEE
JOHN A.LAM E.COUNTY ENGINEER ATION ROBERT A.WOOD,CHIEF PLBG. INSPECTOR
L44 5 0 4E, JAN25 4 3.0 0.
C91110810-63
7eAe�6AB4tD APPLICATION FOR PFERMIT
u
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DtPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION BUILDING d
WIITEM ,C9om7 G! K
Q ADDRESS jr
LOCALITY
N EAR[BT
FOR APPLICANT TO FILL IN `RQ55 ST.
LEGAL
D[BCRIPTION LOT NO, OWNER
MAIL
FLOCK TRACT ���� ADDRESS
NO. OF BLDGS. 11
SIZE OF LOT NOW ON LOT JA� A
Y TEL. NO. CJ
USE OF TRICT NO. GROUP MAP PROCESSED SY
■UILDIHG■
■K Pd
CONTRALTO I-ax ! 1
ADDRW CONNECTION DATA
CITY TZ L, NO. 3 ` DEPTH
ff—CNHOLE RLF6R[NC[ �REGISTRATION NO, � C ✓'�No. DESCRIPTION OF WORK FI[ TYPE OF CONNECTION LENGTH FROM
HODS[BEWER CONNECTING TO CURE M.L TO P.L.
FUELIC SEWER $5.00 'f[DTIC A ,6 O[FI OR F.C.NO. O
P fTa AND/OR DRAINFIELD 510.00 .IMF.NO. j JOS HO.q USE SEWER CONNECTING TO UNK PERMIT H0. ROAD PERMIT NO. (,Y
PRIVATE DISPOSAL UYSTIM 55.00
CONNECT ADDITIONAL■ .OR FIDAVIT f,unL wKR[R RECORD.INSTR.NO. DATE
WORK TO HOUSEB[W[Rf5.00
OVERFLOW■SEP/.GE PIT,DRAINFI[LDKXTN.,CISSPOOL.DRYWELL..MANHOLE $5.00 O_
L ,R ARP A D Y■ Y.OR ST.WIDKNIP40 NSEWER OR DISPOSAL SYSTEM 5.00 AT[ENCROACHMENT
PERMIT NO.
If INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT i Y 00 cHAnocs
AUTHORIZATION TOTAL FEE CONNECTION CHARGE PEI
'1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON. RN
E I MBURSEMLT FEE
RA
TCTOR TO CONNECT THE ABOVE DISCRIBm p(Iil'TINO DWLLLINO ��T�� �►a
TO THE PUBLIC SEWER. APPHOVAI.S DAT[ INSP j,IONATUR[
SIGNEE5 THIS DAY OR
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRIJS 5LFInC TANK,BEEP,PIT(S)
IH
ACKNOWLEDGE THAT 1 HAVE READ THI■ APPLICATION AND/OR DRAINFI[LD
AND STATE THAT THE ABOVE IB CORRECT AND AdRkI TO COMPLY
WrTH ASYL COUNTORDINANCES AND STATE LAWS REGULATING C[B SPOOL [I DRYW[LL
PLUMBING AND SW[RS.
[ ❑
IHEREBY CERTIFY THAT I AM PROPERLY RIOT STE RID ANO/OR ALTER.REPAIR,SEWER OR
LICENSED Al REQUIRED BY LOB ANGLES COUNTY AND STAT[ OF BIWAGE DISPOSAL BYSTIM
CALIFORNIA OR THAT I AM TH[ LEGAL OWNER OF. AND INTEND TO DISCONNKcT PLUO AND
RESI D[ IN, THE 6LPOVK D RIBED RESIDENT 4 PR OP[RTY. ABANDON HOUBI 517WER
■IGNATUR[ ❑
SAC KFILL■[ G TANKS J
OF P[RMIPIT{/)� C[51 POO
ALMATION ROBERT A. D
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
2 1 0 2�8 x' 17 1 0 0 7.40- V
WORKERS'COMPENSATION DECLARATION CE 806{2-80) APPLICATION FOR PERMIT
I hereby affirm that I have ■ certificate of courant to self ` SEWER—SEWAGE DISPOSAL
insure, or { certificate of Workers'Compensation Insurance,or
a cartifled Copy thereof(Sec.3800,Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy No. Company
'Certified copy is hereby furnished.
FOR APPLICANT TO FILL IN CONNECTION DATA
BUILDING j� ��/� J STATION DEPT"TH
Certified copy 4 filed with the county building inspection ADDREsr /V/ �a/
�f\ UPPER
department. LOCALITY G@ C i7Y MANHOLE R[r[R[NC[
LOWER
Date Applicant NEAREST ��) I j f TYPE OF CONNECTION L[N6TH FROM
CERTIFICATE OF EXtMPTION FROM WORKERS' CRO.. Sr. f/{/ r/V Y.
CUR■ P.L. M.L. TO P.L.
COMPENSATION INSURANCE In R /ll r.C. N0.
OWNER V� CO. IMP. NO. JON NO.
by
section y�neede not be completed if
the W/o& Cavo V0d ADORES• TRUNK PERMIT NO. ROAD r[RMIT NO. �ar
�+J two �+�++` Is 1� one hU17lLCR1 lM�li!■ ($Iw) �j ) � AFFIDAVIT WAMWA /Alp�fT w■CORD.IMrtw,NO. DAT.
CITYT[L. HO
,;�RA�
I certify that in the performance Of the work for which this LEGAL
permit Is issued, I &hail not employ any person in any manner DESCRIPTION LOT No. HO
WY. OR ■T. WIDENING Ur
so as to become/]�rubject to the Workers' Compensation Laws. �)
•�P 6�,� \ O f�'� � ■TACK TRACT �+ STATE ENCROACHMENT (L
�[ts�/L�CyYr(J`)(=� r1Jl �R7`-L-/ � PER MIT NO.
Da Applicant � MO. OF ■LOG.. 05
NOT CE TO APPLICANT: If, after making this Certiflcate of SIZE or LOT Nolr ON LOT Z
Exemption, you should become subject to the Workers' uS[ of S b - CHARGES
Compensation provisions of the Labor Code, you must forth- ■ulLDlnG■ T
with comply with such provisions or this permit shall be CONTRACTOR N CONNECTION CHARGE F[[
deemed revoked,
LICENSED CONTRACTORS DECLARATION ADDRESS !�6 }/) REIMEUR[EMENT rE[
I hereby affirm that I am licensed under provisions of Chapter a1Tv O V v DISTRICT NO. awour ■K YAr M �w ■/�■D■
9 (commencing with Section 7000) of Division 3 of the Bud- 2
news and Professions Code, and my license is in full force and a-rATk No LILA.• -o JI/
t-3 6- ,3 3
effect.
No. DIISCRIPTION OF WORK F[E FINAL T VALIDATION
HOU/./EWER CONNECTING TO DATE
License Numb Llc.Clan nJELIc SEWN"
SEPTIC TA"K,SEEPAGE PIT OR
� �-� PIT1 AMO�Ow DwA1NF1ELD
Cbrit-rac ��'�� • Date 17 PINAL
HOUSE SEWER CONNECTING TO
O PRIVATE DISrOSAL SYSTEM oY
I em exempt from the licensing requirements an I am a
CONNECT ADDITIONAL■LD■.OR
licensed architect or a registered professional engineer WORK To HOUSE/EWER '
acting In my professional capacity (Sectloh 7051, Bus- OVERFLOW/E rAGE MT,DRAINFI 9`Dmess and Professions Code). Ex TN.,CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DI/POSAL SYSTEM
Lica or Reg_No. Date �' I
HOME OWNER-BUII.DER DECLARATION
I hereby affirm that I am exempt from the Contractor's OWNER'S Permit
res
License Law for the following reason (Section 7031.5, Buzi- AUTHORIZATION TOTAL FEE
new and Professlons Code): 1 HAVE AT THIS DATE A CONTRACT WITH THE HERE' AHED COR-
OTRACTOR TO CONNECT THE ABOVE DE/CRI■EO jAI ST1Ne DWELUN■
I, as owner of the property, will do the work and the TO THE Pu■uD a
structure is not Intended or offered for sale (Section zi..TNI DwY F t90 a+ ;R 2'6.6,0 A
7044, Business and Professions Code). OWNEROR
OWNERS ASSN # 0 0.0 0 1 0
CONSTRUCTION LENDING AGENCY AODRE/S Z Q O O
I hereby affirm that there is a construction lending agency 0
for the performance of the work for which this permit is o
issued (Sec. 3097,Civ.C.). o 0 0 a 0 0
Leader's Name
Lender's Address
I certify that I have read this application and state that the
above Information is correct. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and h y authorize representatives of this County to enter
u n e bove-m I ed property f on purposes. -SEE
� EE REVERSE FOR EXPLANATORY LANGUAGE
C
of Permittee Date