HomeMy Public PortalAbout10527 KEY WEST ST_Sewer__ DEPAWrMENT OF COUMCY ENGENEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT O FILL IN - LOCALITY
BUILDING NEAREST
ADDRESS o
i CROSS ST.
LOCALITY DISTRICT NO SERIAL NO PERMIT NO...
NEAREST �rry f- CD A/J 7' 2 f L 4G / S
CROSS ST / ! {
I J RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL r f
ADDRESS USE ZONE OCCU pPAANCYBK MAP PG
CITY C TEL N0.
CONTRACTOR r^
CO.IMP.NO f `
ADDRESS
JOB NO. '
CITY 7 TEL.NO. -J1j(/!� 3 TRUNK PERMIT N0.
STATE
REGISTRATION NO /
COUNTY 'ROAD PERMIT NO
LEGAL ee a f41� w�Os
DESCRIPTION LOT NO. S STATE ENCROACHMENT �
d ee O PERMIT NO
BLOCK e TRACT INDUSTRIAL
WASTE APPROVAL
SIZE CF LOTS()/ N0.OF BLDGS.
NOW ON LOT CHARGES
USE OF
BUILDINGS �A CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE O `-
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @_$ 350 RECEIPT N0. I DATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00 %r
ALTER OR REPAIR EXISTING NO DATE I BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION �� !_ DEPTH / A
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2 00 �� 1 A�MANHP LLEE RREFERENCE r p J LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT I 00 'Y _CURB P..L.. ML TO P L
AUTHORIZATION TOTAL FEE 1.4711-CD
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS--..J—?------DAY OF..... __I NEW HOUSE SEWER ,f OWNER ter,
CONNECT ADDITIONAL r�
OWNERS AGENT �' � -. --• ------ BUILDING OR WORK
----
ADDRESS -..---------_------_------- - ---•----- �- SEPTIC TANK,SEEP.PIT(S)
- - - - - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE 1
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES C NTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR T 1 AM THE LEGA WN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBE BACKFILL SEPTIC TANKS E]
SIGNATURE y SEEP PIT(S)0 CESSPOOLS
OF PERMITTEE..--'.- ..... ..... _-- -----
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