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HomeMy Public PortalAbout6221 HART AVE_Sewer__ r���y--� �p �}ao (a� rrl,3�. I ��h.�o . CESOB?8.58 AP8 UCAT N FOR PL�RMT COUNTY OF LOS ANGELES SEWER—S E WAGx.E D O S POSA , DEPARTMENT OF COUNTY.ENGINEER ., BUILDING AND SAFETY DIVISION fBUILDING / JOHN A. LAMBIE, County Fmgineer DDRESS CASSATT D. GRIFFIN, Sup't of Building. OCALITYEARESTFOR APPLICANT TO FILL INROSS ST. �(> Z''<'; C� k' LEGAL OWNER DESCRIPTION LOT NO. MAIL BLOCK TRACT a 00 ADDRESSJW0.OF BLfDGS. o,/•{� SIZE OF LOT NOW ON LOT (Y L CITY .N0. �/ K 7 L USE OF BUILDINGS r DISTRICT NO.I GROUP -r --MAP PROCESSED BY Y� BK`a, PG CONTRACTOR ADDRESS (!J CONNECTION DATA CITY & f EL. NO ❑ STATION DEPTHTATE , REGISTRATION N0. a ❑ZV COUNTY �` 'MANHOLE REFERENCE - UPPER NO.: DESCRIPTION OF WORK FE R, HOUSE SEWER CONNECTING TO n _ PUBLIC SEWER @ $3.00 C T SEPTIC TANK, SEEPAGE PIT OR u TYPE OFION LENGTH FROM Y• URB P.L. M.L.TO P.L. PITS AND/OR DRAINFIELD @ $3.00 _ - ,4 OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 HOUSE SEWER CONNECTING TO �(�'�/ P.C.NO. � PRIVATE DISPOSAL SYSTEM @ $1.00 _CO.IMP.NO. fj J JOB NO. l CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE SEWER @ $1.00 -TRUNK PERMIT NO. ROAD PERMIT NO.qc,�.A/ ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM @ $1.00 _PERMIT NO. INDUSTRIAL WASTE APPROVAL , CHARGES OVMER'S PERMIT $ 2 00 CONNECTION CHARGE FEE ,e AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBE EXISTING DWELLING TO THE PUBLIC/SEW r SIGNED THIS DAY OF 1 sA NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL y; c _ OWNERS ENT- BUILDING OR WORK It i < ' SEPTIC TANK,SEEP,PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE• THAT 1 HAVE READ THIS A#LICATION - '_' AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑ 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 1 AM THE LEG L--OWNER OF THE OVE DESCRIBED RESIDENTIA OP x ,1 'BACKFILL SEPTIC TANKS❑ SIGNATURE j 61 i SEEP.PITS) ❑ CESSPOOLS❑ OF PERMIT TE �/ s �� ®P VALIDATION ROBERTA.WOOD „ M.0« CAB$ SUPERVISING MECHANICAL,ENGINEER ( fir 6 8 1 6 OCT 3 (; 1 0 A Jc.� o n • WORKERS'•,COMPENSATION DECLARATION ;I fizreby�a#irm that I have a certificate of consent to self 'insure, or a'certifieote,of Workers'Compensation Insurance, or 76A642D a certifies'copy thereof (Sec 3800, Lab C.) CE BDB(Rev.a/et). / PPLOCA700H FOR nE(�n T Policy No.� Company ©s u-vl�1�L� U`v u u v FOR IT I�UVII ❑ Certified copy is hereby furnished. ����� ������ ®���®��� ❑ 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' BUILDING �.77 STATION DEPTH AA, COMPENSATION INSURANCE ADDRESS �jC� (This section need not be completed'if the work involved by the LOCALITY p♦� /. MANHOLE REFERENCE UPPER OWER permit is for one hundred dollars ($100)or less.) - LENGTH FROM NEAREST TYPE OF CONNECTION I certify that in the performance he work for which this CROS5 ST. Y. CURB P.I. M.L.TO P.L. permit is issued, I shall not emplo a y erson in any manner so as to be ome ub'ect To the nsation LOWS. `^ I y P.C.NO. I P OWNER S�tN CO.IMP.NO. JOB NO: r MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date / t/Applicant ADDRESS NOTICE APPLICANT: If, after makin this Certificate Of G (� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g' CITY � TEL.NO. ,J Exemption, you should become subject to the. •Worke s' 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 PERMIT No. LOT 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 effect. CONTRACTOR CONNECTION CHARGE FEE License Number LIC.ClassREIMBURSEMENT FEE ADDRESS O, Contractor DateDISTRICT NO. GR UP MAP PROCESS BY V . CITY TEL.NO. � BK PG ❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. 'CLASS sQO r� Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE V FINAL NALIDATI HOUSE SEWER CONNECTING TO � DATE � B. &P. Code for the following reason PUBLIC SEWER J' SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD • Date- - BY HOUSE SEWER CONNECTING TO CIV . 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 E41LL.,c OL,DRYWELL,MANHOLE r7 Law for the following reason (Secton 7031.5, Buisness and Pro- 4w; OR ABANDON HOUSE I O 2 685 '/ A fessions Code): - - ISPOSAL 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 14 v-.;-;2A5 0 Xand Professions-Code). OWNER'S Permit s (J Q 1,as owner of the property, am exclusively contracting with AUThIORIZATION TOTAL FEE - °•°I°.211.,5 v" licensed COn1raCTOrS 10 construct the project(Section,7044, I HAVE AT'THIS DATE,A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO /f p 7 Business and Professions Code). HAVE THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. Q 4,it .5:t.8' CONSTRUCTION LENDING AGENCY I hereby affirm that there is o 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 - ADDRESS - - Lender's Name Lender's Address I certif hat I have read this application and state that the 45ignal in rmation is correct. I agree to comply with all County nc s nd State laws regulating Plumbing and Sewers, e by a ize representatives of this County to enter a e-m nt'aned property for ins ction urposes. ure of ermittee D to f SEE REVERSE FOR EXPLANATORY LANGUAGE