HomeMy Public PortalAbout4929 HALLOWELL AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES NO
WILLIAM J. FOX, COUNTY ENGINEER I ADDREISS p�✓�a ���
FOR APPLICANT TO FILL IN LOCALITY
ADDRESS L ¢.¢r�g QQ CROSS ST. p L,i F' K
LOCALITY ���� DISTRICT NO. SERIAL NO. ^` /&,,PERMIT NO. c
NEAREST A ,J �S-RJ
CROSS ST. t. '—
_ �\ /��RE 6VED BY Ready for Inspection J�D�E ISSUED
OWNER
MAILr USE ZONE OCCUPANCY MAP
ADDRESS 3d'!'`'9 �p � � �. e T I- SK PG
CITY ° TEL.NO.
CONTRACTOR Co.imp.N0. 13.2-1
ADDRESS u` AVE. JOB.NO.
59.33�QL�rER�I
CITY TEMPLE CITY, CAQJJ!• .NO. / TRUNK PERMIT NO.
REGISTRATION NO. /4Z7,* -3- COUNTY ROAD PERMIT NO. 2 9 5 � 32LEGL
S
DESCRIPTION LOT NO./►f S 7� �?g�' 07-GGA STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT MR -9,) - C 3 — INDUSTRIAL
p WASTE APPROVAL
SIZE OF LOT .f 7�1 7 D NOW ON LOTS CHARGES 9
USE
—BUILDINGS Pzil CONNECTION C FEE
�/„!'(
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER $ 3.50 RECEIPT NO. 4I ATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR a� EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 N0.
ALTER OR REPAIR EXISTING I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA _
SEPTIC TANK,SEEPAGE PIT OR 0
PITS AND/OR DRAINFIELD 2.00 STATION 8}� �� DEPTH
CESSPOOL—DRYWELL
_SPECIAL CONDITIONS ONLY 2.00 / MANHOLE�REFERENCE LOWER
TYPE OF CONNEOTIO LENGTH FROM �D
OWNERS PERMIT $ 1 00 Y. CURB f� P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE 4- 1
CONTRACTOR HAVE TO CONNECT DATE THEED TOABOVE DESCRIBED WITH THE HEREI
SCRIBEDI EXISTING ED APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS....ZZ ...DAY OF 19 NEW HOUSE SEWER
OWNER OR _ - CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
ADDRESS. ........... ... _. .-.......... ...... -....... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL❑
.CATIONAND 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 IAM PROPERLY REGISTERED DISCONNECT
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
ABANDON HOPLUG PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER'OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS _ !'
SIGNATURE C, IVOTTtP9GHAIN OF
OF PERMITTEE,, SEEP.PIT(S)[] CESSPOOLS �Ew�^�%" '" ;y
OF PERMITTEE- ---• -- - -- - ....--------
76AG42A 663 7/5
WORKERS'COMPENSATION DECLARATION
I iieheby Offirm that I have a certificate of consent to self 76A647 DPW 6189
nsure, or a certificate of Workers' Compensation Insurance, or,
76AEa2D
C,
certified copy hereof (Sec 3800, Lob C ) 4 - A LICATION F09 PERMIT
Polity 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' [F1
ING STATION DEPTFi
COMPENSATION INSURANCE ESS l
(This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER
LOWER
permit is for one hundred dollars ($100)or less ) LITY
EST TYPE OF CONNECTION LENGTH FROM
I certify that In the performance of the work for which this S sr Q Y CURB P L M L TO P L
permit is Issued, 1 shall not employ any person In any manner GAL PC NO
so as to become subject to the Workers' Compensation Lows RIPTION LOT NO CO IMP NO OB NO
K- TRACT ' TRUNK PERMIT NO ROAD PERMIT NO '
Date Applicant AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
SOR o
NOTICE TO APPLICANT If, after making this Certificate of OOK a PAGE/ PARCELExemption, you should become subject to the Workers' No of eLOGs
Compensation provisions of the Labor code, you must forthwith F LOT NOW ON LOT HWY OR ST WIDENING
comply with such provisions or this permit shall be deemed Frevoked INGS STATE ENCROACHMENTPERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I Om licensed under provisions of ChapterER9 (commencing with Section 7000) of Division 3 of the Busl- MAIL ESS '49 PAU 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
I CONTRACTOR
DISTRICT NO GROUP MAP PROCESSED BY
Contractor Date
ADDRESS p BK PG
❑ I am exempt under Sec of the L A Co 5— (r a
CITY TEL NO
0
VALIDATION v
PlumbingCode and/or Sec of the STATE LIC FINAL !,
LICENSE NO + CLASS DATE - ,� �1
B & P Code for the following reason NO DESCRIPTION OF WORK FEE �J /// Z
HOUSE SEWER CONNECTING TO FINAL H
Date PUBLIC SEWER BY W
SEPTIC TANK SEEPAGE PIT OR '
PITS AND OR DRAINFIELD 0-
Signature
OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING TO ► 2
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from the Contractor's License CONNECT ADDITIONAL BLDG OR
Law or the following reason (Secton 7031 5, Buisness and Pro- WORK TO HOUSE SEWER is
fes ions Code) OVERFLOW SEEPAGE PIT DRAINFIELD ..
EXTN CESSPOOL-DRYWELL 'T.
MANHOLE •j-il.w,I 3
!,'cis owner of theproperty,or m em to employees with wages a5 ALTER,-REPAIR OR ABANDON HOUSE �'((',,z _
Y P Y g SEWER OR DISPOSAL SYSTEM �:30,,J j E i
their sole compensation, will do the work and the structure -��
is not intended or offered for sale (Section 7044, Business I 1 i ENr
and Professions Code)
❑ j, as owner of the property, am exclusively contracting with OWNERS Permit $ a TOTAL 5_5 ® 71D
licensed contractors to Construct the project (Section 7044,
Business and Professions Code) AUTHORIZATION . TOTAL FEE ) CHECK cam•?I1
CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO L.H441-i
CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER
I hereby affirm that there is a construction lending agency -
for the performance of the work for which this permit Is
Issued (Sec 3097, Civ C ) SIGNED THIS DAY OF 19_
OWNER OR UV 1
Lender's Name OWNERS AGENT
AM
Lender's Address ADDRESS 03 11
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'hereby authorize represent es of this County to enter ;
upon the abov -mentioned p pe ty for Inspection purposes
Sig lure of Permittee- Date SEE REVERSE FOR EXPLANATORY LANGUAGE