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Home My Public Portal About5944 HART AVE_Sewer__ p24650 IN ISEE S(� �I 76A64 D !r PPP `C/�TMN FOR 11 tl ER{IVI T • 76A642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSALS J� DEPARTMENT OF COUNTY ENGINEER .' Y.•'° BUILDING AND SAFETY DIVISION a BUILDING ADDRESS .t� JOHN A. LAMBIE, County Engineer E WILLIAM A. JENSEN. Supt of Building LOCALITY' le ... �.- t .:,.'< NEAREST FO APPLICANT TO FILL IN ceoss sr. / LEGAL O G:�`Z OWNER \.T G - DESCRIPTION L N0. c.J BLOCK TRACT 5 —7 G Oji MAIL .• _1 ADDRESS NO.OF BLD SIZE OF LOT NOW 0 LOT ` CITY TEL. NO. USE OF .. .. BUILDINGS Qv� DISTRICT N0. GROU MAP /g PROCESSED BY CONTRACTOR ® � e _ ' ADDRESS ° '� (� - J•.� CONNECTION DATA - CITY TEL.N0. ❑ 'COUNTY "D STATION t,� DEPTH + REGISTRATION N0. ❑ COU TY MANHOLE REFERENCE `' I No. DESCRIPTION 0 WORK FEE ,F HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 E- TYPE OF NN CTION LENGTH FROM 5 SEPTIC TANK,SEEPAGE PIT OR Y. CUR P.L. M.L.TO P.L. PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN..CESSPOOL, DRYWELL @ $2.00 HOUSE SEWER CONNECTING TO •� P.C.N0. _ CO.IMP. NO. JOB NO. PRIVATE DISPOSAL SYSTEM @ $1.00 z W CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. •' V - ALTER REPAIR OR ON SEWER•OR DISPOSAL SYSDEM HOUSE @ $1.00 STATE ENCROACHMENT (q PERMIT NO. O INDUSTRIAL - - U '8 WASTE APPROVAL 14 N a e CHARGES OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE , INSPECIVR'S SIGNATURE TO THE PUBLIC SEVER. SIGNED THIS DAY' NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT M BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD I HEREBYACKNOWLEDGETHAT 1 HAVE READ THIS APPLICATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY - CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR - PLUMBINgEE EWE SEWAGE DISPOSAL SYSTEM 1 HEREClTHAT I AM PROPE EGISTERED AND/OR DISCONNECT PLUG AND LICENSEDD BY LOS ANGEL UNTY A D STATE OF ABANDON HOUSE SEWER n i CALIFORN1 AM THE LE N THE ABOVE BACKFILL TANKS ❑ DESCRIBEL PROP RTY. SEEP.PIT(S) ❑ CESSPOOLSSIGNATUOF PER yi,.....•,.' .�,.t - 'vow-.�n'• `t ..,iX;.' .:.,e. <- ,.� ✓ �....: L. = ®F VALIDAT,Ic�^@ ROBERT WOOD CK. Id.0. IJ4 cA/5R/jl SUPERVISING MECHANICAL ENGINEER _ WORKERS'COMPENSATION DECLARATION I hereby affirm that'I..hav-a certificate of consent to self 76 642D PW 3^87 insure, or a'certificate of Workers'Compensation Insurance, or CE 808 o Cert f.ied copy th'ereof (Sec. 3800,,1ab C.) APPUCATTOO N FOR DDER U Policy`No. Company Os F-1Certifiedcopy is hereby furnished. �� g�� Q��O�Q� ❑ 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' ESS y � STATION �a- • DEPTH COMPENSATION INSURANCE ADDR (This section need not be completed if the work involved by the LOCALITY MANHOLE.REFERENCE Lo permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CO ON LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. C eRB P.L. M.L.TO P.L. _ permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER /' CO.IMP.NO. JOB NO. C, JOB NO. _ MAIL L TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS (r ' this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making CITY � TEL.NO. +✓ Exemption, you should become .subject to the Workers' 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 LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter 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 CONNECTION CHARGE FEE effect CONTRACTOR License Number LIC.Class ADDRESS REIMBURSEMENT FEE d O Contractor DateDISTRICT NO. GROUP MAP PROCESSED BY V CITY TEL.NO. BK PG - Z El am exempt under Sec. of the L.A.Co STATE LIC.LICENSE NO. CLASS 3 etre a[.' NO. DESCRIPTION OF WORK FEE U PlumbingCode and/or Sec. of the FINAL HOUSE SEWER CONNECTING TO �J DATE VALIDATION W PUBLIC SEWER !la B. 8 P. Code for the following reason - N SEPTIC TANK,SEEPAGE PIT OR FINAL Date - PITS AND/ORDRAINFIELD ,— HOUSE SEWER CONNECTING TO BY AA- PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR D OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Bulsnes8 and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE Op licensed contractors to construct the project Section 7044, CONTRACTORs;."'`•- „ _`i -€ P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. • CONSTRUCTION LENDING AGENCY °} I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ CH r¢IGE for the.performance of the work for which this permit is OWNER A P P OWNERS AGENT_ issued (Sec:3097, Civ. C.). ADDRESS _ Lender's NameD 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 ruby authorize representatives,of this County to enter u o the above-mentioned perty for 'nspection purposes. ' _ 2 1 I a r Date SEE REVERSE FOR EXPLANATORY LANGUAGE