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HomeMy Public PortalAbout9813 LA ROSA DR_Sewer__ T°Aa`°° Deeoe a-u, APPLICATION FOR PERMIT " 7 )� COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL d " DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION ADDRESS G C IA39ATT D.GRRIIFFIN, Supt of Building LOCALITY C/ Hnoei Ig NEAREST �a FOR APPLICANT TO FILL IN CROSS ST. L c� 1 AL DESCRIPTION LOT NO. OWNER F - L BLOCK TRACT MAIL s� ADDRESS .J N0.OF BLDGS. 512E OF LOT NOW ON LOT CITY � TEL. NO. � n USE OF BUILDINGS �C+�' DISTRICT N0. GROUP _MAP pe P CESBED BY / CONTRACTOR' i I C�L ADDRESS -1 T CONNECTION DATA CITY -� TEL.NO. p STATION DEPTH - REGISTRATION N0. O B COUNTY MANHOLE RE ERENCE 111,7 TATE NO. DESCRIPTION O WORK FEE IJ�JN-l ��.T" PHOUSEUBLICSWERCONNECTING TO @ .OU _ C�-[J / I t4 & `cM*MA TYPEOF N$ ION LENGTH FROM SEPTIC TANK.SEEPAGE PIT OR Y. CURB M.L.TO P.L. PITS AND/OR DRAINFIELD @ .00 OVERFLOW SEEPAGE PIT, DRAINFIELD E.YTN.,CES SPOOL. DRYWELL .00 HOUSE SEWER CONNECTING TO P.C.N0. PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. ,� JOB NO. WORK TOT ADDITIONALOUSE BLDG.OR @ E 00 TRUNK PERMIT NO. ROAD PERMIT N0. L ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL STATE ENCROACHMENT SYSTEM @ .00 PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ Q OD CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE ) REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEj TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWAPPROVALS D TE INSPECTOR'S SIGN fTURE TO THE PUBLIC SEWER. % SIGNED THIS DAY OF NEW ROUSE FEWER OWNERS AGENT OWNER OR ONNECT ADDITIONAL ' ✓Y v UILDING OR WORK ADDRESS EPTIC TANK,SEEP.PIT IS) ND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPL AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO ESSPOOL ❑ DRYWELL 0 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGUALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM IHEREBY CERTIFT THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STBANDON HOUSE SEWER CALIFORNIA OR THAT I M THE LEGAL OWNER OF HE DESCRIBED RESIDENTI OPERTY. BACKFILL SEPTIC TANKS ❑ SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS ❑ 7 OF PERMITTE ®. I U VALIDATION---, ROBERT WOOD _ CK, M. M o. CASH SUPERVISING MECHANICAL ENGINEER �7�r�1 7 9 9 7 (D 1 U D 7.aC7 eT TBA6A2e C APPLICATION FOR PERMIT ��13 aeoe e•ee,�;' COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING / ADDRESS ]JOHN A. LGRIFFI Comfy Engineer C14SSATC D. GRIFFIN. Supt oS Suildivp LOCALITY FOR APPLICANT TO FILL IN CROSS ST.LEAfl DESCRIPTION LOT N0. OWNER .C. BLOCK TRACT 4 / MAIL ADDRESS NO.OF BLDGS. SIZE OF LOT NOW ON LOT 14 CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUPBK MAP PG OCESSED BY CONTRACTOR �I� ADDRESS CONNECTION DATA CITY TEL.NO. C� .,n ATION_ DEPTH ,e STATE MANHOLE REFERENCE _ UPPER REGISTRATION N0. L COUNTY Sc NO. DESCRIPTION O WOR FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ s .00 TYPE OF CONN TI LENGTH FROM ITS AND/OR DRAINFIELDSEPTIC TANK,SEEPAGE IT OR @ S .00 Y' U / M.I.TO P.L. OVERFLOW SEEPAGE PIT. DRAINFIELD EXTN..CESSPOOL. DRYWELL @ 5 .00 HOUSE SEWER CONNECTING TO P.C.NO. - PRIVATE DISPOSAL SYSTEM @ 51 00 CO.IMP. N0. Cti JOB NO. CONNECT ADDITION BLDG.OR WORK C HOUSE SEWER @ S .00 TRUNK PERMIT NO. ROAD PERMIT NO. i ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEW ER ORD OSAL SYST M @ .00 PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE D REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19_ NEW HOUSE OWNER J v , CONNECT ADDITIONAL A OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PITS) AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR PLUMBING AND SEWERS. ALTER.REPAIR, SEWERDISPOSAL EM 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGDISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISC ABANDON CT PLUG AND CALIFORNIA OR THAT 1 A THE LEGAL OWNER OF THE ABOVEHOUSE DESCRIBED RESIDENT[,* P PERTY. 1 SEEPP (S ❑ FLLSEPTIC TANKS ClS 'ISIGNATURE I l { OF PERMITTEE ®' VALIDATION,----) ROBERT A. WOOD Qy M-p �y/J/ SUPERVISING MECHANICAL ENGINEER L:;,1 8 © 3 fl?F. 3 0 1 1 D 25.00 l WORKERS' COMPENSATION DECLARATION I, hereby cffirmAthat I have o certificate of consent to self jl insure, ar a Certificate of Workers' Compensation Insurance; or - 7ene42D U a certified copy thereof S " 3800 C. CE 808(REV.I,BB) APPLICATION FOR PERMIT Policy Nowa�d. ( pony � mo n�i SEWER - SEWAGE DISPOSAL ❑ Certified copy is hereby furnished. ' ❑ Certified copy is filed with thellunty buildin ihs on 'COUNTY OF LOS ANGELES- � BUILDING AND SAFETY department. _ Date 11 �Applimnt FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' Bu Lot STATION DEPTH COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for,one hundred dollars ($100)or less.) LOCALITY LOMP NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.0 TO P.L. •permit is issued, I shall not employ any person in any mannerP.0NO. I so as to become subject to the Workers'Compensation Laws . OWNER U L J� CO.IMP.NO. JOB NO, MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Dale Applicant ADDRESS re..."-- NOTICE TO*APPLICANT: If, after making this Certificate of CITY TEL NO, AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO, HWY.OR ST.WIDENING comply with such provisions or,this permit.shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. hereby affirm that SIZE OF LOT NOW ON LOT am licensed under provisions of Chapter USE 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 c a_` effect. ¢' �{ R CONTRACTOR r EI� YN ` CONNECTION CHARGE FEE License'Number S %7� Lic.Class r - REIMBURSEMENT FEE (� �../ ADDRESS Contra Ctarl-4-06 Y�L Date >>``C DISTRICT NO. GROUP MAP PROCESSED BY O. CITY TEL.NO. `J73 S �) (I BK V ❑ I am exempt under Sec. of the.I.A.Ca. LICENSE NO,TE LIC MLA ss F E/(Y K Of . Plumbing Code and/or Sec. of the NODESCRIPTION OF WORK FEE OFINAL _ ALIDA I N 1­iHOUSE SEWER CONNECTING TO DATE V B. 8 P. COdefor the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR0W. PITS AND/OR DRAINFIELD FINAL N Date HOUSE SEWER CONNECTING TO BY Z PRIVATE DISPOSAL SYSTEM ' Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION r WORK TO HOUSE SEWER . hereby affirm that I `m exempt from the Contractor's license OVERFLOW SEEPAGE PIT. DRAINFIELDEXTN.,CESSPOOL.DRYWEU,MANHOLE Low for the following reason (Sector,7031.5, Buisness and Pro- ALTER REPAIR OR ABANDON HOUSE fessions Cade): SEWER OR DISPOSAL SYSTEM 'r ❑ I,as owner of the property, or my employees with wages as their sole compensation, will do the work and the structure R 3 1 1. 5 A is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ # • • • ! 1 0 ' ❑ I,as owner of the property, am�exclusively contracting with AUTHORIZATION TOTAL FEE S(Z •( • `Z 1.50 licensed contractors t0 construct the protect (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. e • Q 1. 5 v CONSTRUCTION LENDING AGENCY , ( Q 1 O-8 1 hereby affirm that there is a construction lending agency SIGNED THIS DAV OF I9_ for the performance of the work for which this permit is OWNER OWNERS AGENT issued (Sec. 3097, Civ. C,). ADoafss Lender's Name Lender's•Address ' I certify that I have read this application and state that the above into motion is Correct. I agree to comply with all County . oMnr e lawsregale i g Plumbing and Sewers, ae represent t' s of this County to enter utionedinspection pu poseittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE