HomeMy Public PortalAbout10504 KEY WEST ST_Sewer__ DEPARTMENT OF COUNTY ENGINEER it SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER ! BUILDING
ADDRESS
FOR APPJlCAI`tP FILL IN LOCALITY ,
BUILDING NEAREST `
ADDRESS (/ CROSS ST ( _
LOCALITY DISTRI TNO SERIAL NO. PERMIT
EAREST A 36106>,007
CROSS ST /
EC 1 ED•BY Ready for Inspection DATE ISSUED
OWNER
I '
MAIL I ?E ZOgIE �I OCCUPANCY BK MAP _
ADDRESS_ ' A / P
CITY TEL N0. D
CONTRACTOR CO.IMP.NO.
ADDRESS 'J�= JOB.NO.
CITY / TEL.NO. 6sa TRUNK PERMIT NO.
STATE
REGISTRATION NO. Q COUNTYI ROAD PERMIT NO. �g S F 3
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO _ C PERMIT NO
BLOCK 'FjTRACTq0INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT 8� N0.NOW
OF BLDGS. J CHARGES
6N? ON LO �
USE OF
BUILDINGS CONNE ON CHARGE FEE
NO. DESCRIPTION O ORK FEE
_ REIMBURSEME EE
HOUSE SEWER CONNECTING TO
PUBLICSEWER $ 350 31 5 RECEIPT NO. DA{ I BY
HOUSE SEWER CONNECTING TO
P RIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG.OR /P7R EXCEPTION RECOR ED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00 NO
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR / �• S" DEPTH /
PITS-AND/OR DRAINFIELD 2.00 � STATION l
SPEC AL CONDITIONS ONLY 2 00I r� MA FERENCE
O
6. J UPPER
TYPE OF CONNECTIO LENGTH FROM
Y CURB P L. M L TO P L'
OWNERS PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED;
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TOT PU LIC SEWER
SIGNED THIS-- D OF.... _ 19 , NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR { BUILDING OR WORK
OWNERS AGENT-. -- - '-�. SEPTIC TANK,SEEP.PITS) -
ADDRESS --- -..._.._.._.._......_......--•---_.._._.......----.--....----._.._-_ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL E] DRYWELL
CA
TIONAND 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
AND STATE OF CALIFORNIA OR THAT�1 AM THE LEGALWN-t ABANDON HOUSE SEWER
ER OF THE ABOVE SCRIBED RESIDENTIAL BROPERTY7OBACKFILL SEPTIC TANKS E _
A SEEP PIT(S)� CESSPOOLS]
SIGNATURE (�
OFP
PERMITTE
76A642A 663 7/53 I