HomeMy Public PortalAbout5616 HALLOWELL AVE_Sewer__ D
S&E-689 11.55 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer NG / / .�q _
County of Los Angeles AD RESS lO y�?��
JOHN A. LAMBlE,COUNTY ENGINEER �^
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT
T TO FILL IN T
NEAREST. 3MLEGAL
—DESCRIPTION LOT NO.1V '21Vn�]L 18 S YO L 19 OWNERMAIL
� P_ ���'✓��` r��l+__.�
BLOCK TRACT 12332 ADDRESS A5�6,,16 $allowell ''-ye® s
N0.OF BLDGS. ,� CITY Arcadia, TEL. NO. 1J0 851
SIZE OF LOT NOW ON LOT
USE OF Residence a1 DISTRICT NO.
BUILDINGS GROUP MAP
_ K PG
CONTRACTOR ^i
�. C
ADDRESS CONNECTION DATA
STATION DEPTH 6
CITY . 441rEL. NO.
MANHOLE R FERENCE o UPPE
TATE
REGISTRATI N N ��❑ COUNTY
NO. DESCRIPTION OF WORKI FEE
YPE OF CONNECTIO LENGTH FROM /
HOUSE SEWER CONNECTING TO P.L. M.L.TO P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
-EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 CO. IMP, NO. JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TR K-PERMIT NO. ROAD_,,PERMIT NO.
s CONNECT ADDITIONAL BLDG.OR STA ENCROACHMENT -
WORK TO HOUSE SEWER @ $1.00 PERMI O.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
C R�G E
CONNECTION CARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE REIN NAMED CON. APPROVALS DATE INSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBEDI EXISTING DWELLING �lV
TO THE PUBLIC SEW ." NEW HOUSE SEWER
SIGNED THIS A 0 F 19� CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT
SEPTIC TANK,SEEP, PITS)
ADDRE5616 Hallowell Ave. 9 Arcadia • AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
IB RES ENTIAL I,OPER BACKFILL SEPTIC TANKS❑ > v / �f
N SEEP. PITS) ❑ CESSPOOL 6 G`'r10�'
P Mi E y
JOHN A. LAMB E. CouN E (NEER VALIDATIO ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. m CASH
WORKERS'COMPENSATION DECLARATION
k hereby`affirm that 1 have a certificate of consent to self
insure!or a certificate of Workers'Compensation Insurance, or 76A642D
P certified p ereo(Seee- n800 b c. J i1 92-0002 DPW 6/88 APPLICATION FOR PERMIT
LJ �ertiffed copy is her'e�b�y(furnished. „/ SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
department
Date 9'1- �/ Applicant A�� FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING /// STATION y,�-a 3. DEPTH I
COMPENSATION INSURANCE ADDRESS (O (® CCCC
(This section need not be completed if the work Involved by the LOCALITY MANHOLE REFERENCE S
LOWER
permit is for one hundred dollars ($100)Or I@55.) LENGTH FROM�455 f
I certify that in the performance of the work for which this NEARESsr. TYPE Of CONNECTION
permit is issued, I shall not employ any person in any manner n Y CURB M.L.TO P.L.
so as to become subject to the Workers'Compensation Laws. �S _ P.C.NO.
OWNER D&AJ CO.IMP.NO. JOB NO.
MAIL ,.1 TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS �n• LA
NOTICE TO APPLICANT: If, after making this Certificate Of CITY TEL.NO.
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
Exemption, you should become subject to the Workers' �� ZS'�
LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. - BLOCK TRACT STATE ENCROACHMENT a
LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO.
1 hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT
USE OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
effect. (, CONTRACTOR CONNECTION CHARGE FEE
License Number b LIC.Class C v 3 ADDRESS REIMBURSEMENT FEE 8
3' , DISTRICT NO. GROUP MAP PROCESSED BY qZ
Contractor ftJ Date _ CITY TEL.NO. BK PG v
Yr -y�-- -3 A 3
El STATE LIC. I
I am exempt under Sec. of the L.A.Co. LICENSE No. CLASS
DESCRIPTION OF WORK FEE
Plumbing Code and/or Sec. of the No. FINAL
HOUSE SEWER CONNECTING TO OJ/�D DATEVALIDATION (q
B. & P. Code for the following reason PUBLIC SEWER p!i
SEPTIC TANK,SEEPAGE PIT OR e
PITS AND/OR DRAINFIELD
FINAL
Date HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR J
W R-BUILDER DECLARATION WORK TO HOUSE SEWER / 0
OVERFLOW SEEPAGE PIT,DRAINFIELD 5i
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE d
fessions Code): SEWER OR DISPOSAL SYSTEM
❑ I,as owner of the property,or my employees with wages as 3_307 t J d
their sole compensation, will do the work and the structure
is not intended or offered for sole (Section 7044, Business Permit $ Q� I TTS '_
and Professions Code). OWNER'S
El 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE i='"T1;u 4-8 m ryf
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CAUNTRACTOR TO ''i•e-E
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY ® M IGE _i
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT F { j
ADDRESS 0101?Q-0100 i 'rS� r i 1
Lender'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 hereby authorize representatives of this County to enter
I/u`pon the abo e-Mentioned property for inspection purposes.
ign ure o Permittee Date / SEE REVERSE FOR EXPLANATORY LANGUAGE