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HomeMy Public PortalAbout10062 GREEN ST_Sewer__ II w CE11011 3,62APPLICATION FOR PERMIT 76A642D 42D ((jj COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION ZADDRESS / JOHN A. LAMBIE, County Engineer oWILLIAM A. JENSEN, Supt of Building FOR APP I A T_7_ .FILL . LEGAL VVI DESCRIPTION LOT O. OWNERIf MAIL t /� BLOCK _ ADDRESS NO. OF SLOGS. SIZE OF LOT NOW ON LOT GIT TEL. NO. USE OF DISTRICT NO. GROUP MAP OGESSED BY BUILDINGS BK PG /1 CONTRACTOR- A&niA ADDRESS ---••iff��� CONNECTION DATA CITY TEL. NO.,4/1-1 STATION DEPTH TATE MANHOLE REF ENCE UPPER REGISTRATION NO. 1J.5-'01 S COUNTY LOWER NO. DESCRIPTION OF WORK FEE TYPE OF CON CT LENGTH ROM HOUSE SEWER CONNECTING TO Y. CUR P.L. M.L.T P.L. O PUBLIC SEWER @ $5.00 P.G.N SEPTIC TANK.SEEPAGE PIT OR CO.IMP.NO. JOBA V PITS AND/OR DRAINFIELD @ $10.00 � HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. �tfSAD PERMIT NO. O PRIVATE DISPOSAL SYSTEM @ $3.00 G CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT CORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 — (JJ OVERFLOW SEEPAGE PIT,DRAINFIELD d EXTN.,CESSPOOL,DRYWELL,MANHOLE S5.00 �N�yj ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENIN L SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHM T PERMIT NO. INDUSTRIAL WASTE APPRO AL OWNERS PERMIT $ i 00 CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF _19— OWNER 9_OWNER OR NEW HOUSE SEWER OWNERS AGENT_ CONNECT ADDITIONAL ADDRESS Z' K, BUILDING OR WORK '1 .0 SEPTIC TANK,SEEP,PIT(S) 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABO DESCRIBED RE ENT PROPERTY. ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS El FERMI - SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER CCASH i WORKERS'COMPENSATION DECLARATION T/. CIO I hat affltm that I have a certificate of consent to self Inwre or certificate of Workers Cbmpersatlon Insurance, Or 7ana111D CE°°°WV.e'°'' APPLICATION FOR PERMIT ❑Coolfled copy Is hereby furnished. SEWER - SEWAGE-DISPOSAL �ertified copy Is filed with the county building Inspectlon COUNTY OF LOS ANGELIES BUILD G AND SAFETY deportment. Date 11 4ze fe FOR APPLICANT TQ FILL IN CONNECTION DATA CERTIFICATE OF 6)ffJMPTION FReOA WORKERS' STATION ` [-TI COAAPBJSATION INSURANCE A J (fhfa section need hot be completed If the work Involved by the LOCALITY �� MAN»pr REQ r u�t perr411t Is for ono hundred dollars (2100)or less ) TYPE Of Qor+1aC.T�CNta"GTti ICM I certify-that In the performance of the work for which this Y QM _Pu Mu TO P.L. } permit Is Issued, I shall not employ any person In any manner 1L so as to become/ubiect to the Workerd Compensation Laws. 0whu CC).VAP.NO t,p. .0 ` � V DateT�Applicant TAS SWT NO. ROAD PbNNTT No. NOTICE Tb APPLICANT: If, after making this Certificate of. QTY TEL NOAm=FDAvrr wANER EASEmarT wcOw. No. DATE G -Exemptlon, you should become subject to the Workers 41419 LEGAL Compensation'provislons of thq Labor code, you must forthwith' Dg( pT� LOT NO. Hwy. d comply with such provisions or this permit shall be dgembd �'ws>E NG (A revoked,' BLOCK TRACT STATE ff4QK)AQHME tT _ •Z LICENSED CONTRACTORS DECLARATION` �goEior I hereby affirm that I am licensed under provisions of Chd ter 9 (commencing with Section 7000) of Division 3 6f the Bull-, �w� o-URp© ness and Professions Code, and my license it Ln full force and affect. CON ECTTorr CHARGE FEE License Uc.Cla�A e.y ASS r$ '• . Con e O �� DfSrRICr fJC�, GROUP AW hK PG ❑ I am exempt under Sac._ of the l A Co. STATE LK'_ LKaM NO. CLASS Plumbing Code and/or Sec. ofthe NO_ DESCRIPT10tsl OF WORK FEE aNu YWLx . SEWER CQCTING TO [SATE � r�j'1� ? 'VALIDATION B, d P. Code for the foflowing reason errs ASD/ &IpAdE Prr OR DRAINFLELD MN-AL . _ Date'- HOUSE.SEWER CON NECTMG TO BY Signature N TO )NAI I OR OWNER-BUILDER DECLARATION sE£PAa RT DRAT NFELD , J I hereby affirm that t am exempt from.the Contractor's License +xTN MANHOLE Law for the following reas6n (Se4t6n 7031.5, Bulsness and Pro- gl REPAIR CR A&Ah�HOUSE sslfeons Code): 6707, -1.4.2,9,9 A' ❑ I,as owner of the properly,6r my employees with waQgs aj their sole congpensatlon, will do the worts and the structure # o 0 0 0,� Is not Intended or offered for sole (Section 7041, Buslness 2 0 2,] 5 O and Professions Code), OWN491S Permit f � 0 . r ❑ I, as owner of the Prop",am exclusively contracting with ALITKORIZATION TOTAL FEE o 0 0 2 7.5 OT-' licensed contractors to construct the pr6ject (Section 7044, i tAvt AT THIS DATE ., T TFE NsmN tJrhS®CONTRACTOR TO Business and Professions Cotte). cct#r:cT TFE AeovE Dw"C Ea oasm4r,Dwain,TO THE KmucSEwEX 0 a 0 5—8 3 CONSTRUCTION LENDING AGENCY I hereby affirm thbt there Is d tru -consction lending agency '1®T11� D°for the performance of the work for which this permit Is OWNER Issued (Sec. 3097, Cly. C,). Lender's Name Lender's Address I cwilfy that I have rood this application dnd state that the above Information Is correct. I agree to comply with all County ordlnances and State laws regulating Plumbing and Sewers, a hereby authorize reprbsentafives of this Cobnty to enter the above-mentloned Irgpection pub. Sign ofPermlttee Dans SO WVMRPOR DMIANW09Y LANGUAGG