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HomeMy Public PortalAbout5937 IVAR AVE_Sewer__ 76A 642D-CE808 A-7/76 APPLICATION F R PERMIT SEWER—SEWAGE DISPOSAL u COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FOIZ APPLICANT TO FILL IN DISTRICT NO. GROUP �SK� MAP /Po PR CESSE BY BUILDING -./l� /�/'�. /P ADDRESS ,� Z/ I )/ L G� CONNECTION DATA LOCALITY NEARESTSTATION DEPTH CROSS ST. q �� UPPER MANHOLE REFERENCE LOWER OWNER �N>D��- M F} ��+ TYPE OF CONNECTION LENGTH FROM MAIL �+ IV A/� Y. CURB P.L. M.L.TO P.L. ' ADDRESS Y K P.G.NO. T �� A CO.IMP.NO. JOB NO. CITY • • •TEL. NO. V LEGAL • / TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. AFFIDAVIT I WAIVER EASEMENT I RECORD.INSTR.NO. DATE BLOCK TRACT U ` NO. O, BLDG.. - SIZE OF LOT )C / NOW . LOT HWY.OR ST.WIDENING USE OF STATE ENCROACHMENT BUILDINGS• PERMIT NO. � CONTRACTOR L&WK U NLAM IZ'Ep Cpm INDUSTRIAL ^ �' WASTE APPROVAL, ADDRESS j644�J. �.G���Jy CHARGES CITY Ed>A TEL. NO. 99�•G91,3 CONNECTION CHARGE FEE C9 STATE /�� LIC REIMBURSEMENT FEE LICENSE NO.. Q( b CLASS NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE HOUSE SEWER CONNECTING TO - PUBLIC SEWER @ (� SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER PITS AND/OR DRAINFIELD @ CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM SEPTIC TANK.SEEP,PIT(S) f� CONNECT ADDITIONAL BLDG.OR AND/OR DRAINFIELD Y6 yWAIWWJC=�HOUSE SEWERy�_ OVERFLOW SEEPAGE PIT,DRAT FIELD CESSPOOL ❑ DRYWELL ❑ EXTN..C_ESSPOOL.DRYWELL.MANHOLE ALTER,REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS ❑ SEEP.PIT(S) ClCESSPOOLS OWNER"S Issuance Fee $ I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AUTHORIZATION TOTAL FEE AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. PLUMBING AND SEWERS. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING i HEREBY CERTIFY THAT- 1 AM PROPERLY.REGISTERED AND/OR TO THE PUBLIC SEWER. LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SIGNED THIS I CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO OWNER OR R SIDE IN, THE.ABOVEI DESCRIBED RESIDENTIALO�_PERTY. `OWNERS AGENT ._•�. IGNATURE E II a---�(71�✓ -I i IR/t OF PERMTfTEE ���OOO in NNN��.rYY AUD I CK. M.O. CASH. 5 9 7 r JUL 14 1 0 9 9.0 d` E808 D CEeos APPLICATION LmICtl' T9 N 0 O tl PERMIT 0F9'SIT ++-s� COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION rADDRESSUILDING JOHN A. LANZIE, County Engineer 0 CASSATT D. GRIFFIN, Supt of Sui}diag oCALiTY FOR APPLICANT TO FILL IN CROSS s'. LEGAL / DESCRIPTION •LOT NO .5V % OWNER BLOCK TRACT � MAIL - ADDR S LJ NO'.OF BLDGS. [SIZE OF LOT,;,� X / ` NOW ON LOT CIT 0. USE OF ` BUILDINGS �/Jr� "t? .,r_�f�- DIST R_ICT NO. « OUP [' MAP P/� CONTRACTOR C��% C�''� I � I lyI ADDRESS v j ,! 4%.57/, `_- CONNECTION DATA ///tltltl 111 CITY _ C .J 'TEL.NO. �7 ( ^� STATION � ��l a q DEPTH l / ❑ STATE MANHOLE REFERENCE / w -} UPPER REGISTRATION N0. t ,❑ COUNTY NO. DESCRIPTION OF WORK FEE / HOUSE SEWER CONNECTING TO ' PUBLIC SEWER @ $3. SEPTIC TANK.SEEPAGE PIT OR TYPE OF QN LENGTH FROM �aa O ITS AND/OR DRAINFIELD @ $3.00 Y. CU B P.L. M.L.TO P.L. OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOL_ @ $2.00 HOUSE SEWER CONNECTING Tt) _ �0 PRIVATE DISPOSAL SYSTEM ` :I @ $1.00 CO.IMP.NO. v JOB NO. CONNECT ADDITIONAL BLDG.OR .�� WORK TO HOUSE SEWER !@ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. :, ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM @ $1.00 - STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS-, PERMIT - $ 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE"' Q REIMBURSEMENT FEE TRACTOR TO CIONNECT THE ABOVE ESCRIBED'EXISTING NAMED APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. Qom,, SIGNED THIS ^� DAY OF/ Tom✓/lL�'/�'� 19 NEW HOUSE SEWER -2 OWNER OR CONNECT ADDITIONAL - - - - -. �! i OWNERS AGEN C � BUILDING OR WORK , ADDRESS t� SEPTIC-TANK,SEEP,PITS) - - - AND/OR DRAINFIELD _ IH ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -CESSPOOL❑ DRYWELL•❑ WITH ALL COUNTY' ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS, - ALTER,REPAIR,SEWER OR I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM - - LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT I AM THE L GAC. OWNER OF THE?ABOVE_ ABANDON HOUSE SEWER DESCRIBED„RESIDE IAL P PE TrY. //+j BACKFILL SIGNATURE. c � Sr`^-d-w'�.-. .CESSPOOLS OF PERMITT E -"'�""��• OFLIDATION ROBERT A. WOOD i CK. td.0. CASH SUPERVISING MECHANICAL ENGINEER WORKERS',COMPENSATION DECLARATION I heraby affirm that I have a certificate of consent to self insure,or cert�i`icate of Workers'Compensation Insurance, or 76A642D a certified cony thereof(Sec. 3800, Lab C.) CE BDB(REV.B/B,) APPLICATION FOR PERMIT Policy No. Company ©$ ❑ 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 nj f'� �,V`rn`v` STATION DEPTH COMPENSATION INSURANCE ADDRESS J / — (This section need not be completed if the work involved by the ^�L t MANHOLE REFERENCEUPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER I certify that In the performance Of the work for which this NEAREST TYPE TYPE OF CONNECTION LENGTH FROM permit is issued, I shall not employ y person any n CROSS Y. CURB P.L. M.L.TO P.L. so as to become subject to the rs'Comp ati - OWNER CO.IMP.NO. JOB NO. it ci�n MAIL eL TRUNK PERMIT NO. ROAD PERMIT NO, Date2—\�—� Applicant ADDRESS v AFFIDAVIT =NTJ RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this. C ificate of CITY TEL.NO. Exemption, you should become subject to Ale 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 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 Q w•C 1/, sy yt ,� t k CONNECTION CHARGE FEE License Number Lic.Class ADDRESS A,� REIMBURSEMENT FEE Contractor Date CITY q, Cv4 TEL.NO. LlLS yAs—.s S DISTRICT NO. GROUP MAP PROCES D BY S BK �P ❑ I am exempt under Se of the L.A.Co. STATELICENNO. �® O•Z LIC.CLA �`/ 0 Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL L9 HOUSE SEWER CONNECTING TO DATE 7 VALIDATION Ii. B. 8 P. Code for the{allowing reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FIN g Date - HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD6 51,.9 A I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Sectors 7031.5, Buisne55 and Pro- ALTER,REPAIR OR ABANDON HOUSE 0 1 feS5iOn5 Code): � SEWER OR DISPOSAL SYSTEM 0 0 0 0 ❑ I,as owner of the property,or my employees with wages as I•( 0,° 2.1,5 Q their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Businesso 0.0 21.5 0 5 and Professions Code). OWNER'S Permit $ I lo LS-0 ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE S x,2,,1 7 8 7 licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY , 1` 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 i 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 law regulati g Plumbing and Sewers, and hereby puthorize es t' es 0 this County to enter upon t ove-men ' e ty nspection urposes. Signature of Perm�a Date SEE REVERSE FOR EXPLANATORY LANGUAGE