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HomeMy Public PortalAbout4835 HELEO AVE_Sewer__ i D S&E-663 12.54 APPL,ICATIOIV ,I=OR PEPERMITS& .61 DMSION OF BUILDING AND SAFETY -SEWER-SEWAGE ®ISPOSAL Department of County Engineer County of LOS Angeles BUILDING 1 WM. J. FOX. COUNTY ENGINEER :ADDRESS CASSATT D. GRIFFIN, SUPT OF BUILDING LO'A' FOR APPLICANT TO FILL IN CROSS ST . LEGAL DESCRIPTION LOT N0. (/ OWNER BLOCK C/ TRACT MAIL /3r/3 .7 /�j ADDRESS � DrD'1 to , SIZE OF LOT (�, (/�NOWOONBLOTS. !) /f,�/ CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUP' MAP BK PG CONTRACTOR ADDRESS elf3 `7, 11fL11 .; �; /,Jr�, CONNECTION DATA CITY �TEL. NO.`�.�V 1--,7 L STATION - ® DEPTH <y ❑ STATE �,( �� MANHOLE REFERENCE LOWER REGISTRATION N0, v ❑ COUNTY (F F r TYPE 05 TION LENGTH FROM NO. DESCRIPTION OF WORK FEE Y. URB A P.L. M.L.TO P.L. � '1 HOUSE SEWER CONNECTING TOc� PUBLIC SENlER ct $ 3.50 16-0 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 ' CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. ® �Y JOB. NO. WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING SEWER OR DISPOSALSYSTEM M 1.00 TRUNK PERMIT N0. ROAD PERMIT NO .2 9 DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO. SEPTIC TANK, SEEPAGE PIT OR _ PITS AND/OR DRAiNF1ELD 13.00 INDUSTRIAL CESSPOOL-DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CHARGES CONNECTION CHARGE FEE OWNER'S PERN2UT $ 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT qq FEE T�+ TRACTORHAVE T TOS CONNECT THE.DATE CONTRA ABOVECTED WDESCRBEDITH THE HEREIN EXISTINGNAMED DWELLING APPR®tlALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER ii pp NEW HOUSE SEWER SIGNED THIS DAY OF 19_ .' OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK. SEEP, PIT($) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL[IAND 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 IHEREBY CERTIFY THAT 1 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 LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ l 5� i F\ SEEP, PIT(S) ❑ CESSPOOLS SIGNATURE OF PERMITTEE WILLIAM J. FOX.COUNTY ENGINEER VALIDATION BY BY DEPUTY .,,.,�,//.�JJJ� DEPUTY BY BY ;® DEPUTY DEPUTY WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a'certificate of consent to self ILf� insure, or a certificate of Workers'Compensation Insurance, or 7eAe42D a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No. Company ©s ❑ 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' BUILDING ! STATION DEPTH COMPENSATION INSURANCE ADDRESS - (This section need not be completed if the work involved by the /� MANHOLE REFERENCE UPPER. permit is for one hundred dollars ($100)or less.) LOCALITY ` LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST: Y. . CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in anyanner so as to become subject to the Work s'Compensatio aws. OWNER e Q�� CO.IMP.NO. JOB NO. 1_ MAIL Dat r Applicant ADDRESS1170fol"ke TRUNK PERMIT NO. ROAD PERMIT NO. 129 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.NO. Exemption, you should become subject to the Workers' LEGAL L8i 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 effect. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE Contractor Date DISTRICT NO. GROUP MAP P CESSED IY CITY TEL.NO. BK PG ❑ I am exempt under Sec. of the L.A.Co. STATE LIC. j P LICENSE NO. CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTIO OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE ��d1_V2 VALIDATION PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAICONNECTING ate HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signatur CONNECT ADDITIONAL BLDG.OR ► OWNER-BUILDCL ER D ARATION 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, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE2 8 9 A fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as # 0 0 0 0 1 Q their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 2 0 0 21.50 and Professions Code). OWNERS Permit $ d �� ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE 'L4 0.0 .o 2 1,5 0 P�. licensed Contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO �( 6-83 V p Z Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. _ 06 1 ­8 J CONSTRUCTION LENDING AGENCY , 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 ADDRESS 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 repeesentati sof this County to enter po the ove-mentioned prop ty for inspect' purposes. �r6— ignoture of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE