HomeMy Public PortalAbout9802 HOWLAND DR_Sewer__ 0-,x."..",` = APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bull C A JOHN A. LAMBIE. COUNTY ENGINEER ADDRE85 L , / Die
COLEMAN W. JENKINS. SUPT. OF BUILDING FOCALITY NEwRESTFOR APPLICANT TO FILL IIV `RDE• .T.LEGAL .E Dig �E' L�
DESCRIPTION LOT NO. OWNER
MAIL E S c
BLOCK TRACT v ADDRESS
NO. OF eLTB. q
512E OF LOT NOW ON LOOT CITY TEL NO.
USE OF
BUILDINGS A DISTRICT NO. GROUP MAP PROCESSED BY
BE
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL. NO.
STATION DEPTH
STATE LIC UPPER
LICENSE NO. CLASS MANHOLE REFERENCE
LOWER
NO. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER a 55.00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO/
PITS AND/OR GRAINFIELD ® fID.OD CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® 53.00 TRUNK PERMIT NO. AD PERMIT NO.
CONNECT HBLD [
IT
G.OR AFFIDAVIT WAIY[l AS[YIMi RECORD.INSTf♦, DATE (�
WORK TO HOUSEOUSE SEWEWER R 33.00 ��
1'
OVERFLOW SEEPAGE WELL.GRAINFIELD Q
ALTER.
ESSPOOOR ABANDON HOUSE ® $5.00
ALTER.REPAIR OR ABANDON HOUSE HWT.OR BT.WIDENING U
SEWER OR DISPOSAL SYSTEM 33.00 W
STATE ENCROACHMENT D-
�y _ PERMIT
I. ! • _ 1 l INDUSTRIAL
v WASTE APPROVAL
CHARGES
OWNERS pEAMTI s If 00
ff22 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �'� V t
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO,CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR5 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BWLOI NO OR WORK
FDISCONNECT
TANK.SEEP,PITIS)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIONR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. OL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED PND/OR EPAIR.'SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO PLUG ANG
, TXE ABOV DESCRIBED RE31 ENTI L PROPERTY. ONHOVSESEWERSIGNATURE
OF PERMRTEE LL SEPTIC TANKSIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
VALIDATION
o. CASH SUPERVISING
\MECHANICAL ENGINEER
r�
LAC,! 6 9 0 9' S&24 1 0 D 5.00-
IN
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have o certificate of consent to self
insure, or a certificate of Workers'CompensotiominWrance, or' 76AM2D
a certified ca� thereof (Sec. 3800, Lob AC�.) Sy R2-°�2DPW 81aB APPLICATION FOR PERMIT
Policy Ncf� 6�� am P.0 T.C/! /j�C J(f 6
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL . '
certified copy is filed with ounty buildin ction COUNTY OF LOS ANGELES BUILDING AND SAFETY
artmenl.
Date Applic FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE E PTION F WORKERS' WILD NO Q-7i Q moi/ T
C SATION INSURANCE ADDRI:Ss '/ STATION DEPTH
(This section need not be completed if the work involved by the r �• MANHOLE REFERENCE UPPER
permit is for one hundred dollars ($100)or less.) LOCALITY L6 �! LOWER
I certify that In the performance of the work for which this F REST TYPE OF CONNECTION „ LENGTH FROM
permit is issued, I shall not employ any person in any manner CROSS ST. Y. CURB PA. M,L.TO P.L.P.C.NO.
so as to become subject to the Workers'Compensation Laws. OWNER CO.IMP.NO. .LOB NO.
MAILTRUNK PERMIT NO. ROAD PERMIT NO.
Dote Applicant ADORES,
NOTICE TO APPLICANT: If, after making this Certificate of ?L AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
J
Exemption, you should become subject to theCITY TEL NO.
. 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 PERMITENCROACHMENT
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 G!'�IyfrJ/ MNNEC71ON CHARGE FEE
License N r ��� Lic.Class �/ —/-�L ADDRESS y REIMBURSEMENT FEE - I M 8
CODtra ate r/� �/ DISTRICT NO, GROUP MAP 416
'By
z
CITY TEL.NO, 4r/ /�ZZ BK- ' 1G O
BY
STATE LIC. T m exempt under Sec. of the L.A.Co. LICENSE NO. Z CLASS `7
Plu mbing Code and/or Sec. ofthe NO. DESC IPTION OF WORK FEE FINAL ILI
1KK1SE SEWER CONNECTING TO DATE I ' VATION Z
B. 8 P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE Mr OR FINAL
Dote PITS AND/OR DRAINFIELD FI
MUSE SEWER CONNECTING TO /BY
.
PRIVATE DISPOSAI SYSTE
Signature CONNECT ADDITIONAL BLDG.OR , '
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
' OVERFLOW SEEPAGE PIT,DRAIHOUSE
I hereby affirm that I am exempt from the Contractors License CVERF CESSPOOL E MT.DL MANHOLE
NFIELD
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE ZQ
fession5 Cade): SEWER OR DISPOSAL SYSTEM
AGCi.:
❑ I,their
owner of the property,will
o employees with wages ras
e - - .11,)
Their sole compensation, will do the work and the structure ;317 - 7 L
is not intended or offered for sale (Section 7044, Business
and Professions Code). OWNER'S Permit $ U U 1 ITEMS -
El 1,as owner of the property,am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL 27 . 00
licensed contractors to Construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO FF'Yr
Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWEUING TO THE PUBLIC SEWER. CHECK -)7.O I
CONSTRUCTION LENDING AGENCY �l)
I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ CHANGE
for the performance of the work for which this permit is OWNER OR
issued (Sec. 3097, Civ. C.). OWNERS AGENT '
Lender's Name ADDRESS 0000—OCIL71 6715/90
Lender's Address 13G4 - 1 AM 9:26
1 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,
an by authorize represen ptives of Ih is County to enter
on t above-mention r edy for inspection purposes.
Signatu ermittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE