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Home My Public Portal About5519 HILTON AVE_Sewer__ >6A6420, seE-66S 11-55 APPLICATION FOR PERMIT 1 DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Dep=tment of County Engineer County of Los Angeles BUILDING JOHN A. LAMBIE. COUNTY ENGINEER ADDRE _. ® CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY C NEAREST ` FOR APPLICANT TO FILL IN CROSS Sr. ' LEGAL DESCRIPTION LOT NO. OWNER BLOCK TRACT I� AC� MAIL i- ADDRESS NO. OF BLDGS. CITY TEL. NO. SIZE OF LOT NOW ON LOT- / USE OF _Z r BUILDINGS �L �S%d(P-il Cf'- H%///iJ� DISTRICT NO. GROUP MAP CONTRACTOR_- �1 > ` T BK PG ADDRESS r� STATION T LDEPTH CONNECTION DATA " `/ ^/ �-•/// Ct ✓moi CITY�. .,., -� TEL. NOe� �J f=/ UPPER MANHOLE REFERENCE e7/J/J -%rte '�100,� ❑STATE L7R (i,/J REGISTRATION NO. ❑ COUNTY ' NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TOTYPE OF N CTION LENGTH FROM PUBLIC SEWER @ $3.50 r0 Y. LURB P.L. M.L, TO P.L. SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $ 3.00 / OVERFLOW SEEPAGE PIT, DRAINFIELO ' Z(� Z P C NO U CO. IMP. N0. EXTN..CESSPOOL,DRYWELL,MANHOLE @ $2.00 JOB NO. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT WORK TO HOUSE SEWER @ $1.00 PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM @ S 1.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'S PERMIT S 1 00 REIMBURSEMENT FEE AUTHORIZATION I TOTAL FEE p I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGN ATURE HAVE TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. NEW HOUSE SEWER SIGNED THIS�DAY OF --/� '"� 19✓�� CONNECT ADDITIONAL OWNER OR / �i BUILDING OR WORK OWNERS AGENT f�/y- i.0 i �Y1,f.%7"'^•lam SEPTIC TANK.BEEP,PIT(S) ADDRESS � �-�>/lj � '7411//Q°'>rL� �C/J. AND/OR ORAINFIELO I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND STATE THAT THE ABOVE 15 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 1 AM PROPERLY REGISTERED AND/OR AND LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF pISCONNECT ABANDON HO PLUG PLUGUSE D CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIOENTIA�,PROPERTY. BACKFILL SEPTIC TANKS❑ �✓ C SIGNATURE / i „ ./� / , z. SEEP. PIT(5) [JL7 CESSPOOLS b OF PERMITTEE JOHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLSG. INSPECTOR C 4 6 VIS S CASEPSN � p 11 1 A 4,5 O F WORKERS' COMPENSATION DECLARATION 20D051DPW 6T69 I hereby affirm that I Have a Certificate of consent to self LLLIII iniur�—Dr a cerNficUte of Workers' Compensation Insurance, or 76A642D ° certified copy thereof ,SeLab C , APPLICATION FOR PERMIT Polic y�No. Company anyny ❑ 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. Dote 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 L UPPER OWER MANHOLE REFERENCE permit is for one hundred dollars ($100)or less.) LOCALITY NEAREST _I TYPE OF CONNECTION, LENGTH FROM I cii that in the performance of the work for which this GROSS ST. permit is issued, I shall not employ any person in any manner r CURB PL ML TOPL LEGAL PC NO s0 OS 10 become subject t0 the Workers' Compensation Laws. DESCRIPTION LOT NO. CO IMP NO TOB NO Dole AppIIC°nt BLOCK TRACT TRUNK PERMIT NO ROAD PERMIT NO ASSESSOR AFFIDAVIT I WAIVER EASEMENI RECORD INSTR NO DATE NOTICE TO APPLICANT: If, after making this Certificate of MAPBOOK FACE vARCEL Exemption, you should become subject to the Workers' NO.OF DEEDS. COmpen5olion provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked_ BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION � PERMIT NO t U I hereby affirm that I am licensed under provisions of Chapter OWNER y & 0' 4 9 (commencing with Section 7000) of Division 3 of the Busi- MAILDRESS _ CHARGES •ADS j ,liti Less and Professions Code, and mr, license is in full force and / )]'7y)' ellect. CITYChy C TEL NO. -)-17—C)36 CONNECTION CHARGE FEE License Number Lic Class REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED BY ADDREG$ BK I>G ❑ I am exempt under Sec. of the L.A.Co. clTv TEL NO. -0� _� � �' OF O Plumbing Cade and/or Sec. ofthe STATE LIC. FINAL U LICENSE NO. CLASS DATE VALIDATION Z B. 8 P. Code for the following reason NO. DESCRIPTION OF WORK FEE O HOUSE SEWER CONNECTING TO FINAL f Date PUBLIC SEWER BY W SEPT'C TANK SEEPAGE PIT OR a Signature ITS AND OR DRAINFIELD N OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING IO ' { Z PRIVATE DISPOSAL SYSTEM ALf I hereby affirm that I am exempt from the Contractor's license CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWERHf.;C-raa fessiOns Code): OVERFLOW SEEPAGE PIT DRAINFIELD E'TN CESSPOOL DRYWELL MANHOLE l-+ ?'?• -'30 ❑ I,OS Owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE •4�j),,.5 +•� their sole compensation, will do The work and the structure SEWER OR DISPOSAL SYSTEM j S. EH i tl is not intended or offered for sale (Section 7044, Business v } and Professions Code). I�i i?Y;L -72 #_.� +�� ❑ 1,as owner of the property, am exclusively contracting witht-HE licensed contractors to Construct the project (Section 7044, OWNERS Permit $ GTI Business and Professions Code). AUTHORIZATION TOTAL FEEt;i'�HP�tat Y e%q CONSTRUCTION LENDING AGENCY I HAVE AT IHIS 'DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO I hereby affirm that there is a construction lending agency CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER for the performance of the work for which this permit IsI:lrn_ t(}fl< — }i,'y'� issued (Sec. 3097, CM. C.). SIGNED THIS DAY OF I9_ rl-'I-ff^ �f="1 ``/ OWNER OR hii a'�'-'Ci• Lender's Name OWNERS AGENT 9; 5625'�9; 562r�rl Lender's Address 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 .pan the above-mentioned property for inspection purposes. Signature of PermlRe Dote SEE REVERSE FOR EXPLANATORY LANGUAGE