HomeMy Public PortalAbout4904 KAUFFMAN AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT-APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING�jp /1
.CASSATT D. GRIFFIN, Sua'T DF BuiLDINc: ADDRESS�T% L/•, ����� /=r/Y1,,4 h! ��
FOR APPLICANT TO FILL IN, LOCALITY
BUILDING NEAREST /�Rv5/
ADDRESS CROSS ST. .UJ h
LOCALITY DISTRICT N0. SERIAL NO. PERMIT NO. c
NEAREST' -:5, A "� ,/ ) S
CROSS ST.,;,-
RECEIVED BY Ready.for Inspection DATE ISSUED
OWNER J
MAIL 1
ADDRESS USE ZONE OCCUPANCY MAP
BK PG
CITY TE L.NO.
CONTRACTOR CHARGES REIMBURSEMENT FEE
ADDRESS f � REQUIRED
NOT REQUIRED
CITY.., TEL.NO. , JOB.NO. Dj 7 3 /Z CONNECTION CHARGE FEE
STATE
REGISTRATION.NO. �®r�� GGB TA' CO.IMP. NO. T^
LEGAL /�Q (����[n�t7� F16 f LD RECEIPT N0. DATE _ I BY
DESCRIPTION LOT NOJ ` Q
BLOCK TRACT WAIVER FOR RECORDING
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT � �' RE `�RECEIPT N0. ( DATE BY
USE OF � � � -1
BUILDINGS► s`�j+ �$ T
TRUNK PERMIT NO.
NO. - DESCRIPT60N •OF= WORK FEE.- _
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLICSEWER @ $ 3.50 �'0 Z ?- ??&�
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSALSYSTEM 1.00 PERMIT NO.
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
WORK TO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00
SEPTIC TANK,SEEPAGE PIT OR STATION DEPTH /
PITS AND/OR DRAiNFIELD 2.00 MANHOLE REFERENCE
CESSPOOL—DRYWELLI I UPPER ') )j? 4 ,q s LOWER
SPECIAL CONDITIONS ONLY 2.00 TYPE OF CO NECTIOIA LENGTH FROM
Y. CURB — P.L. M.L.TO P.L.
OWNERS PERMIT $ 1 00 -
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN/ NAMUD:
CONTRAGTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS---�?'--y---DAY OF------- - - --�---------------- I9. Z3_', NEW HOUSE SEWER
OWNER OR '/�/' CONNECT ADDITIONAL
OWNERS AGEN7.�.1 _�-. i BUILDING OR WORK
ADDRESS.�.16-`7. - ------ - :__---- ---- ---------t.-X_ - SEPTIC TANK,SEEP.PITS)
-- AND/OR DRAINFIELD
1 HEREBY ACKNOWLED THAT I AVE READ THIS APPLI-' CESSPOOL D DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSESAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
EWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)E] CESSPOOLS[]
SIGNATUREem
OF PERMITTEE_- -�-�- �----------- t�� -�--------------' _
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