HomeMy Public PortalAbout10150 LA ROSA DR_Sewer__ TEMPLE CITY
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DEnoB.a.>,B APPLICATION FOR- PERMIT" -
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
- i DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION - BUILDING a- Rosa _
ADDRESS
JOHN A. LAMBIE. Counlp Enginoae
'CASBATT D. GRIFFIN. Supe of Building LOCALITY Temple.le. Cit• '
- NEAREST -
FOR APPLICANT TO FILL IN CROSS ST:LEGAL T
DESCRIPTION LOT NO. OWNER John R• F'1t Zgerald
-BLOCK TRACT MAIL esa. lca itoad
ADDRES
'NO.OF SLOGS. E
'.SIZE OF LOT NOW OMLOT CITY TEL.NO.
`USE OF
BUILDINGS Res
rtKPP DISTRICT NO. GROUP BK MAP'PG P CESSED BY
CONTRACTORL.-•• r lF. On'structi On CO. .a / 447 1 JAZ";,
.ADDRESS 5136 North Bleecker - - coxxECTI N AT - - -
CITY. a dwin ark_TEL. N0. ED 8-3024 STATION .f.-g3 - DEPTH
REGISTRATION NO. 113613 STATE. MANHOLE REFERENCE- _ UPPER
COUNT. - 'LO
NO. . DESCRIPTION OF WORK FEE' - -
PUWETF-
BLICS SEWEERCONNECTING TO $3.00 GSC-
SEPTIC TANK:SEEPAGE PIT ORPERF CONNECTION. .LENGTH FROM
D �-
PITS AND/OR RAINFIELD 0 $3.00 Y.' -CURB P.L..'. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD, '
EXTN.,CESSPOOL,DRYWELL:MANHOLE § $2.00 '
HOUSE SEWER CONNECTING TO I P. C, NO.
PRIVATE'DISPOSAL SYSTEM .@.$1.01. CO.IMP.NO. / �'. JOB N0.
'CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER -@ $i-.00 - TRUNK PERMIT NO. ROAD PERMIT N0.
-
ALTER, REPAIR OR ABANDON HOUSE 'STATE ENCROACHMENT
SEWER.OR DISPOSAL SYSTEM PERMIT N0. -
'INDUSTRIAL -
� WASTE APPROVAL '
CHARGES
OWNERS . PST $ Z* 00 'CONNECTION CHARGE.FEE'
AUTHORIZATION FTOTAL FEE REIMBURSEMENT FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS - DATE,- INSPE DR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE'PUBLIC SEWER:
SIGNED THIS DAY OF Ig_ NEW HOUSE SEER
OWNER ORNEW BUIILDING OR WORKNECT A'
OWNERS AGENT
SEPTIC-TANK.SEEP,PIT(S)'
ADDRESS AND/OR DRAINFIELD-
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND,AGREE TO COMPLY CESSPOOL❑ DRYWELL[I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEER OR _
PLUMBING'.AND SEERS. I SEWAGE DISPOSAL.SYSTEM . _
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND..STATE OF ABANDON HOUSE SEER
CALIFORNIA OR 'THA i AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID I L PROP T. BACKFILL SEPTIC TANKS
SIGNATURE ❑ -
• SEEP.PIT(S)
I] CESSPOOLS❑
OF PERMITTE / '
®r. irALIDATION '�ROBERTA.WOOD
RK. n,Y, mat -BUPEHvmNG M6cHANICAL BNOINHBH
GD*3 5'0-5' `UO,, "7 1 C ,D: 5.06 N
WORKERS'COMPENSATION DECLARATION
'x?L Jlereiti affirm that I have a certificate of consent to self -
insute, or o certificate of Workers'Compensation Incur nce, or _ 7aA6A2D
a certifie c y thereat Sec. 3800, L c QJ// _RR-002DPW 610 APPLICATION. FOR PERMIT
❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL
Certified copy is filed with the county buil 'ng inapecro COUNTY OF LOS ANGELES . . BUILDING AND SAFETY department.,/
$n•�,�f^'
Dot. Applimnt R
PLICANT TO•FILL IN CONNECTION DATA' -'
CERTIFICATE OF EXEMPTION FROM RKERS' BU NGQ -
COMPENSATION INSURA - STATION DEPTH
(This section.need-not be completed if the work involved by the MANHOLE REFERENCE uPPeR-
permit is for one hundred dollars ($100)or less.) ,P, i. LOWER
I certify that in the performance of the Work for Which this - ST TYPE OF CONNECTION LENGTH FROM '
permit is issued, I shall not employ any person in any.manner Y. CURB P1. M.L.TO P.L.
so as to become subject to the Workers'Compensation Laws. P.C.NO.
_ _ CO.IMP,NO. JOB NO,
TRUNK PERMIT NO. ROAD PERMIT NO.
Date Applicant
NOTICE TO APPLICANT: if, after makingthis Certificate of J •�I AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
- . LEL NO. oG
Exemption, you should become subject to the Workers'
LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HM.OR Si.WIDENING
comply.with such. provisions or this,permit shall be deemed
revoked. - BLOCK TRACT STATE ENCROACHMENT
LICENSED CONTRACTORS DECLARATION - NO.OF BLDGS. PERMIT No.
1 hereby affirm that I am licensed under provisions of Chapter SIZE TOT NOW ON LOT USE d
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. / CONTRALTO CONNECTION CHARGE FEE
LiCe/Ln/�sy/��N/u�/m�ber /J�V LjC,Clas ?sy ^ 3 REIMBURSEMENT RE
CoI�IIJIYoY'4 ate JDA' /d+ ADDRESS
/ / 'DISTRICT NO. GROUP MAP PROCESSED BY 0
_ CITY rte✓ EL.NO. 6 BK PG
❑ I am exe 1 under Sec. of the L.A.Ca. 5E Np .p V ,cuss
RK FEE Ld
Plumbing Code and/or Secs of the NO: DESCRIPTION OF WORK FINAL yALIDATION p
HOUSE SEWER CONNECTING TO DATE 9
B. 8 P: Code for the following reason J' PUBLIC SEWER • - —3�_ /'/ RG z
_ SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIEID FINAL Ji.
,
Date HOUSESEWERCONNECTINGTO BY ACCT.
PRNATE DISPOSAL SVS }
$ignOlure CONNECT ADDITIONAL BLDG.OR - ,;3137 .7.,
- - OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER - •I - -
OVERFLOW SEEPAGE PIT,DRAINFIELD - 1 ITEMS
I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
O
SEWER R DISPOSAL SYSTEM TOTAL(T TIL 27 —00
fessions Code): _ _
'❑ I,'os owner of the property,or my employees with wages as CHECK 27.00
-their sole'compensotion, will do the work and the structure - CHANE .HT1] .
is not intended orroffered for sale (Section 7044, Business .
and Professions Code). OWNER'S Permit 5 ,
❑ I,as owner of the property,-am exclusively contracting with AUTHORIZATION TOTAL FEE
licensed Contractorslo construct the Project Section 7044, , - [1UUU—O[iDl _10/ .4/90
P I ( I HAVE AT THIS A-CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO
Business and CONSTRUCTION
Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ji;; . i AM!0:29 CONSTRUCTION TENDING AGENCY 9d 1 1 rt
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 isAGENT-L
issued (Sec. 3097, Civ..C.).. -
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 dll County ^ -
ordinances and State laws regulating Plumbing and Sewers, -
and hereby authorize representatives of this County to enter
u t above-me n party ff , inspection purposes. -
c/ %-a3- qd
ignatur arm ittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE ,