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HomeMy Public PortalAbout9805 HOWLAND DR_Sewer__ �o i ID DEPARTilbNT OF COUNTY ENGLNEER SEWER—SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY ' PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER BUILDING /J �DV C ADDRESS "f OD(Jl FOR APPLICANT JO FILL IN �/�/ LOCALITY IN BUILDG 9/ /HOU,/QH�I/✓. CROSSST. C'�-4"'�'•{iLJ-fi'Ci/[ ADDRESS LOCALITY / DISTRI CJ.N0. A uER1AL NO. ^PERMIT NO. c CROSSST. NEAREST 5 0. O 74 `T G� ��r l/�L�_rf — RECEIVED BY ReAOY for Inspection DATE ISSUED O W NERO�.(�// l�I� /��� MAIL ADDRESS /i' QO ` USE20NE OCCUPANCY BKPO `70 J of// �JrJC! �� ]� CITY �/-ntl/P��7EL.NO. P-/ CO NT RACTOR��'Gn rd rm ✓419. L-O• CO.IMP.NO. ADDRESS '�Q �f�X^�ijry JOB.NO. t QTEL.NO.�f�.7 TRUNK PERMIT NO.ISTATE / �1 REGISTRATION NO. 'pej,`-1Q}�f ® COUNTY ROAD PERMIT NO. ;2 7lD pC S LEGAL b STATE ENCROACHMENT DESCRIPTION LOT NO. / - PERMIT NO. BLOCK TRACT / �� INDUSTRIAL E.WASTAPPROVAL SIZE OF LOT '/6D ^y NOW ON LOTS CHARGES USE OF GoroGe CONNECTION CHARGE EE BUILDINGS P,{. NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLICSEWER a $ 3.50 rJ RECEIPT NO. DATE BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR �G E PTION hkCORDED WORK TO HOUSE SEWER 1.00 _ ALTER OR REPAIR EXISTING NO' DAT BY S EWER OR DISPOSAL SYSTEM 1.00 _ AND/OR DISPOSAL SVSTEMN SEWER ) 00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR GRAINFIELD 2.00 STATION � �� DEPTH CESSPOOL-DRYWELL SPECIAL CONDITIONS ONLY 2.00 / � / 0' MANHOLE REFERENCE i (O tlPPLR- LOWER TYPE OF CONNECTION LENGTH FROM 0 0 OWNERS PERMIT 9 1 00 p�e CURB -w Al.L.TOP.L. e AUTHORIZATION TOTAL FEE e5 ( an N i,-'l 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOWSSIGNATURE DATE DWELLING TO THE PUBLIC SEWERY�.: SIGNED THIS._LL.—.._DAY OF_. CC.rJ_�_.._,..195 NEW HOUSE SEWER OWNER OR � � CONNECT ADDITIONAL BUILDING OR WORK OWNERS AGENT....... ..1..__•.,._._..._. ........._..K! .._.__ Q �.. / SEPTIC TANK, FIELD IT(S) ADDRESS.._�.t7.�s�l...���.._.._£�:G.^.u9.. �......_. AND/OR DRAINFIELO 1 HEREBG ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. CESSPOOL 0 DRYWELL CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ANO STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER ER OF THE ABOVE DESCRIBED EK51DENTIAL PROPERTY. BACKFILL SEPTIC TANKS / SIGNATURE //��j))j ,�,,vv SEEP.PIT(S)0 CESSPOOLS' �T .O OF PERMITTEE._//:._%r.G_a.. _.�:.G. ........._....... 76A642A 663 7/53 Jnr Q/ WORKERS'COMPENSATION DECLARATION I hereby-gffirm that I hove a certificate of consent to self _,n4-;re, d certificate of Workers'Compensation Insurance, or �6A6<20 akgnified copy thereof (Sec. 3800, Lab C.) CE 908(REV.B,BI) 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 ( COMPENSATION INSURANCE ADDRESS E) N �• o W /�L'// 2. STATION DEPTH (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOCALITY LOWER I certifythat i0 the NEAREST 11 // iVFE OF CONNECTION LENGTH FROM performance of the work for which this ROSS ST. J C N V URB Pl, M L.TO P L permit is issued, shall not employ an erson in any manner n P.C.NO. so as to become subject to the Wor s' Campensat' {ow5. OWNER (p q q u s'L �.`j Q CO.IMP,NO. JOB NO. MAIL`�/ L ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. DatT'��` APPlimnt N TICS O APPLICANT: If, ft&kIngAFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE ' to if oro of CRY ret.NO / Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor Code, you must forthwith DESCRIPTION LOTNO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT /� 3 O STATE ENCROACHMENT NO.OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT hereby affirm that Se licensed under provisions of Chapter USE OF 9 (commencing with Section d my of Division 3 of the Busi- and BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE t a License Number Lic.Class ADDRESS V, REIMBURSEMENT FEE O Contractor Date L GROUP MAP PROCESSED BY L.7 CITY TEL NO. BK PG Z I am exempt under Sec. of the L.A.Co. LICENSE NO. CLLASS / 4 Z O [OWNER DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO PUBLICSEWERB. 8 P. Code for the following reason VALID ON wSEPTIC TANK,ff MAGI PR ORzPRS AND/OR DRAINFIELDDat¢ HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM /rte Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD hereby affirm that am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the fallowing reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM I, as owner of the property, or my employees with wages as 22 b 1 1.5 A their sole compensation, will do the work and the sfrucNre e • e e,1 0 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ ! (�' 0 e - 2-1.50 . ❑ I, as owner of the property, am exclusively contracting with THORIZATION TOTAL FEE o o e `2.1 5 0 licensed Contractors to construct the project (Section 7044, VE Ai iHls DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR i0 Business and Professions Code), NECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1 CONSTRUCTION LENDING AGENCY ► 2.16-86 I hereby affirm that there is a construction lending agency ED THIS DAV OF � � = 19�� for the performance of the work for which this permit is OR issued (Sec. 3097, Civ.pOWNERS AGENT . S ). � - Lender's Name !\/ G h/i- ADDRESS i 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 a t/IO1IZe rEJqqq rir///iEeEE%EEntOUVes of this County to enter upon the v�ment's�iop/y for it purposes. l )s / EA, 6 to SEE REVERSE FOR EXPLANATORY LANGUAGE