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HomeMy Public PortalAbout9133 HERMOSA DR_Sewer__ CE8003-64 EA04D APPLICATION FOR PERMIT 2IJ COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING •�3 JOHN A. LAMBIE. County Engineer ADDRESS WILLIAM A. JENSEN. Sup1 of Building LOCALITY NEAREGT FOR APPLICANT TO FILL IN CROSS sT. LEGAL DESCRIPTION LOT NO, / OWNER ✓L // MAIL BLOCK TRA7 ADDRESS CT ' NO, OF BLDGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF gICT NO. GROUP "Al PROCESSED BY BUILDINGS A4 K /J�(� PG CONTRACTOR ADDRESS L '(J(/ ✓�' y. CONNECTION DATA _ CITY L. STATION �J ), DEPTH J TATE A HDL. ��� LOWER REGISTRATION NO. / O/ COUNTY' f ./ NO. DESCRIPTION OF WORK FEE TYPE OF CO CTION LENGTH FROM HOUSE SEWER CONNECTING TO Y. P.L, M.L.TO P.L. PUBLIC SEWER a SS.00 SEPTIC TANK.SEEPAGE PIT OR ~ C P.G NO, PITS ANO/OR DRAINFIELD 510.00 CO.IMP'NO. J JOB NO. �Jq O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT / PRIVATE DISPOSAL SYSTEM 53.00 f/ CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER [55I ENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER ® 53.00 O OVERFLOW SEEPAGE PIT,DRAINF I ELO EXYN.,CESSPOOL.ORTWELL.MANHOLE 0 $5.00 W ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING d SEWER OR DISPOSAL SYSTEM Ae 53.00 STATE ENCROACHMENT N PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT s 2 00 AUTHORIZATION TOTAL FEE f CONNECTION CHARGE FEE 'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TO A'THERPU0 CCOBEWERTHE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER T� M OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK,S TIB) HEREBY ACKNOWLEDGE THAT 1 HAVE HEAD THIS APPLICATION pryD/OR DRAINFIELD IELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑ 1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND RESIDE IN. THE ABO D SCRIBED ESIDENTIAL PROQRPEY. ABANDON HOUSE SEWER qq 'A SIGNATURE BACKFILL SEPTIC TANKS ❑ p� '-/1 OF PERMITTEE `2,' DEEP,PIT ISI ❑ CEssp..L3 V LL// VALIDATION,---) ROBERT A: WOOD SUPERVISING MECHANICAL ENGINEER CK. M.0. CASH I Uo 6 3 8 6k2 OCT 13 1 0 D T].O o __ .. WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6/89 U I hereby of3.irm mciI have a certificate of consent to self Insure, &;o certificate of Workers' Compensation Insurance, or 76A642D q Policy No—Company thereof (sec. ny Lab CAPPLICATION FOR PERMIT Pohcy tda. company SEWER - SEWAGE DISPOSAL ❑ 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' BU THING STATION DEPTH COMPENSATION INSURANCE ADDRESS % ! (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE UPPER permit is for one hundred dollars (8100)or less.) NEEST ( M LOWER certify that in the performance of the work for which this cRARoss srTYPE OF CONNECTION LENGTH FROM . r/--©1„ r cuae P ML Tovl permit is issued, 1 shall not employ any person in any manner LEGAL PC No so as to become subject to the Workers Compensation Laws. DESCRIPTION Lor No. Co IMP NO JOB No Dale Applicant BLOCK TRACT UPUNx PERMIT NO ROAD PERMIT NO NOTICE TO APPLICANT: If, after makingthis C2rt ifiCOt2. Of ASSESSOR g a AGFIDPVII WAIVER EASEMENL RECORD INSrR NO DATE MPP BOON _3Jf PAGE D PARCEL C'U 3 Exemption, you should become subject to the Workers' NO OF OLDGS. Compensation provisions of the Labor code, you must forthwith SIZE OF LOT Now ON LOT HWY OR 5T WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUILDINGS & [ r(PL— STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT No I hereby affirm that I am licensed under provisions of Chapter OWNER r IL.L 9 (commencing with Section 7000) of Division 3 of the Basi MAIL J��V CPA-5c— 3'77 R• CHARGES Hess and Professions Code, and my license is in full force and ADDRESS (TG effect, art rIL.No. �' 3 CONNECTION CHARGE FEE L' nicese Number Lic_Class REIMBURSEMENT FEE CONTRACTOR � Contractor Date DISTRICT NO GROUP MAP PROCESSED PH ADDRESS BK - PG ❑ I am exempt under Sec. of the L.A. Co. CITY TEL,No +, � 00 Plumbing Code and/or Sec. of the STATE LIC. NAL U g LICENSE NO. CLASS DATE _ 1! VALIDATION O B, g P. Code for the following faO50n NO. DESCRIPTION OF WORN FEE `f J HOUSE SEWER CONNECTING TO FINAL y` F Date PUBLIC SEWER BY L O SEPTIC TANK SEEPAGE PIT OR 'E 8 W .Signature PITS AND OR GRAINFIELD Wit_': OWNERBUILDERDECLARATION HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM ► _ tis _to-_Z I hereby affirm that I am exempt from the COntrOCtOr'S License CONNECT AoomONAL BLDG OR Law for rh allowin reason Secton 7031 5, Buisness and Pro- I WORK TO HOUSE SEWER a - 9 fessl ode): OVERFLOW SEEPAGE PIT DRawnElo ExTN.CE5SPOOl. DRYWEIL.MANHOLE °5 Owner of the property,Or my employees with wages as ALTER REPAIR OR ABANDON HOUSE I I IL their sole compensation, will do the work and the structure SEWER OR DISPOSAL SYSTEM ;L1r•;.y __ yc is not intended ar offered for sale (Section 7044, Business t`•"L End Professions Code . f'js� t" �1 tat ❑ I,as owner of the property, am exclusively contracting with licensed contractors to construct the project (Section 7044, OWNERS Permit S BLISPISs and Professions Code). AUTHORIZATION TOTAL FEE /R I�?j!jE_—!JI'':1�. CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR To I hereby affirm that there is a construction lending agency coNmEa THE ABOVE DESCRIBED EXISTING DWELLING TO THE vueuc SE WER I'D i FIT 06„'[.' for the performance of the work for which this permit Is t issued (Sec 3097, Civ. C.), SIGNED THIS 0 DAY OFw r; ^ � OWNER A !-- Lenders WN Name OERS AGEN' I _ Lender's Address ADDRESS ;? cwo�q OL. Cc 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 upon the above-mentioned property for inspection purposes. if Signature ol`Per2ilitee Date SEE REVERSE FOR EXPLANATORY LANGUAGE