HomeMy Public PortalAbout10043 LA ROSA DR_Sewer__ /aA642D
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APPLICATION FOR PERMIT_
SEWER - SEWAGE DISPOSAL
COUNTY`OF LOS ANGELES BUILDING AND SAFETY'
FOR APPLICANT TO FILL IN DISTRICT NO(� CRIUI EK MAR FG "I'D BY
noDaess�QQ J 0 M�I � —
LOCALITY' - C L C.fLJF CONNECTION DATA
NEAREST STATION DEPTH
CROSS ST. 1
UPPER
r� MANHOLE REFERENCE LOWER
OWNER / ���fff �� TYPE OF CONNECTION LENGTH FROM
MAIL ,�rr11 j ^ Y. CURB P.L. M.L"TO P.L.
ADDRESS/V0 Q K- ,
'7� Il P.C.NO.
CITY/L/II J C/LJVI TEL.NO. SZs OO.IMP.NO, JOB NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOTNO.
AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT
SIZE OFNO.OF BLDGS
USEOF LOT O NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATEENCROACHMENT ,
PERMIT NO.
INDUSTRIAL /_G
CONTRACTOR WASTE APPROVAL 9 Z Y
ADDRESS CHARGES
CONNECTION CHARGE FEE
CITY TEL.NO.
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. LASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE 111 8
HOUSE SEWER CONNECTING TO m
PUBLICSEWER O
SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CO NN ECTADDITIONAL /�,J�Ii
HOUSE SEWER CONNECTING TO BUILDING OR WORK D WWW
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK,SEEP,PITI51
CONNECT ADDITIONAL BIOS.OR gryp/OR DRAINFIELD
' MCOffihHOUSE'SEWER �
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL C3DRYWELL[-IEMN..CESSPOOL,DRYWELL,MANHOLE
ALTER,REPAIR OR ABANDON HOUSE f
EPAIR,SEWER OR '
SEWER OR DISPOSAL SYSTEM E DISPOSAL SYSTEM
NECT PLUG AND
N HOUSE SE WER
L SEPTIC TANKS Ej
TI510 CESSPOOLS❑
OWNER'S Permit s
AUTHORIZATION TOTAL FEE - VALIDATIONS' - - -
1 HAVE.AT THIS DATE A CONTRACT WITH THE HEREIN NAMED - -
TflACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWE
TOTHE PUBLIC SEWER
SIGNED THISm DAYOF I'
OWNEROR p /� �T
OWNERS AGENT ////'J 1 � CC /��- ��� _ L 44 G 9 H
ADORES S 10"- -2, dJA D /%AO%7c
Jleseel0
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATIONAND '
WITHSALLETHE
UNTYHE ASO E IS CORRORDINANCES ANDSTATE AWS
S CT AND ETO COMPLY
REGUATING 2 O 0 1400
PLUMBING AND SEWERS,
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR
LIOENSEO AB REOUI ED BY LOS A GEIES COUNTY AND STATE OF •O 0 p 1400"
CALIFORNIA ORTH M E EG WNER OF.AND INTEND TO RE-
SIDEIN,THEgBOV D SC D E ID NTIAL PROPERTY. '
o5, 17-79
SIGNATURE
OF PERMITTEE
/L WORKERS'COMPENSATION DECLARATION y�-000s DPW a/ar q
hese!hy.„offirm thot`I have a certificate of consent to self /nnaaso 11SI
insure,or.a certificate of Workers' Compensation Insurance, or CE 81
b certified copy thereof (Sec. Lab C.) APPLICATION FOR PERMIT
Policy No. Compannyy Os
❑ 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 F
OR APPLICANT TO FILL IN _ �, 'CONNECTION'DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' //``JJ�� /� aa .STATION DEPTH
COMPENSATION INSURANCE b LC'. / ,$r'
This section need not be com leted if the Work involved b the UPPER
( p Y /IQ�G�G MANHOLE REFERENCE LOWER
permit isfor one hundred dollars ($700)or less.)
I certify that in the performance of the work for which this r - - - - - TYPE CONNECTION LENGTH FROM
Y P �`r7 f/'�/�
Y. CURB P.L. M.L.T00.L
permit is issued, Shall not employ any person in any manner P.c.NO.
so as to become subject to the Wdrkeri Compensation Laws. { G{7 _ T P/ CO.IMP.No. JOB NO.n TRUNK PERMIT NO. ROAD PERMIT NO,
Date E=/6- Applicant ADDRESS !X7 '.� Rct
NOTICE TO APPLICANT: If, after king this Certificate of ary T ny C,pZ TEL No. -� D AFFIDAVIT WAIVER I EASEMENT RECORD.INSTR.NO, DATE
Exemption, you should become subject to the Workers' LEGAL p / -
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. Por, C HWY.OR ST.WIDENING
comply with such provisions or this permit shall be deemed q�J
revoked, BLOCK TRACT (!jt Z-/ STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION / Q l No.of BL PERMIT PERMn No.
SIZEOFLOi U Lr .UZ NOW ON IDT
I hereby affirm that I Se licensed under provisions of Chapter WE 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 CONNECTION CHARGE FEE
IX
License Number LIC.Class ADDRESS V� �
E O
COOIfOCtOr Dote ly” ROUP MAP PROCESSED BY U
CITY TEL NO. (/(� BK Z
❑ I am exempt under Sec. of the L.A.Co. STATE No. an55 L "LO
NO. DESCRIPTION OF WORK FEEPlumbing Code and/or Sec. of the HOUSE SEWER CONNECTING TO VALIDAT N toB. 8 P. Code for the following reason PUBLIC SEWER //:/Jl M
SEPTIC TANK,SEEPAGE PIT OR WPITS AND/OR DRAINFIELDDate HOUSE SEWER CONNECTING TO , 961, 1 A
PRIVATE DISPOSAL SYSTEMSignature CONNECT ADDITIONAL BLDG.OR # • 1 0
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
,( ,�
I hereby affirm that OVERFLOW SEEPAGE PIT,DRAINFIELD 2.1. 50
am exempt from the Contractor's License EXTN,CESSPOOL.DRVWELL MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE '� 21.505
fse TIS COde): SEWER OR DISPOSAL SYSTEM
LJ I,os owner of the property, or my employees with wages as 05„1 6I-88
their sole compensation, will do the work and the structure
is not intended or Offered for sale (Section 7044, Business
and Professions Code). OWNERS Permit 8 O
❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE -
licensed contractors to construct the project (Section 7044, I.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 ►
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
issued (Sec. 3097, Ci, C.). OWNERS AGENT
ADDRESS
Lender's Name
Lender's Address -
I certify that I have read this application and state that the
above information incorrect. I agree to comply with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter
upon the above-mentioned property for inspection purposes.
Signat &75f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE