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HomeMy Public PortalAbout8841-41 1/2 LAS TUNAS DR_Sewer__ �1IE11 � 76A6424-' !i CE0081REV.6/101 Q3 APPLICATION'FOR PERMIT , , SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT No. GROUR MAR PIS ocessso ev BUILDING ` /AA / /'')r. /yJ'��� -BA 5 ` AGGRESSIZ� W _J'�B✓ TY CON NECTION DATA EARE NEAREST STATION ' DEPTH CROSS ST. UPPER MANHOLE REFERENCE LOWER OWNER ,TYPE OF CONNECTION LENGTH FROM MAIL C p u �J / Y. CURB P.L, M.L.TO P.L. AGGRESS J 'D - F.C.NO. 1 , /1 CO.IMP.NO. JOB NO. CITY TEL.NO. LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOTNO. 1 AFFIDAVIT WAIVER EASEMENT RECORD,INSTR,NO. DATE BLOCK TRACT NO.OF BLDGS. SI2E OF LOT L• ill NOW ON LOT HWY.OR ST.WIDENING U5EOF BUILDINGS STATE ENCROACHMENT PEflM fT NO. tl INDUSTRIAL CONTRACTOO/R/'� / WASTE APPROVAL ADDRESS J90,/ � �/ / CHARGES CITY '✓L' 1f TEL.NO. CONNECTION CHARGE FEE STATE LICREIMBURSEMENT FEELICENSE NO3i70b CUO NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATUREHOUSE SEWER CONNECTING TOPUBLIC SEWER SEPTIC TANK.SEEPAGE PIT ORNEW HDUSE SEWERPITS ANO/OR DRAT NPIELD CONNECT ADDITIONALHOUSE SEWER CONNECTING TO BUILDING ORWORKPRIVATEISPOSALSYSTEM d_CONNECT ADDITIONAL BLDG.OR SEPTIC TANK.SEEP.PITI51 WORKTOHOUSE SEWERANp/Ofl GRAINFIELDOVERFLOW SEEPAGE PIT.GRAINFIELDCESSPOOL ❑ ORYWELL❑ EXTN.,CESSPOOL,DRYWELL.MANHOLE ALTER. IOON HOUSE �� ALTER.i�IV.SEWER SEWER OR M11O�GAL SYSTEM SNy�p1GpYGAl SYSTEM / / JSJ -- "� DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILLSEPTIC YANKS - -OWNER'S Permit SEEP.Pm SI❑ CESSPOOLS❑ AUTHORIZATION TOTAL FEE r VALIDATION t I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-. _ ._- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _ _ 1 80.5 A TOTHE PUBLIC SEWER. SIGNEDTH15 OWNEROR /D AY OAF/!/�y �11�c97 - OWNERS AGENT ��•i© {i/�f� +I r�IO O O 4.00 O, 1 O• ADDRESS �"7 �'r� "E"1 1 L O O 1 Ay.O O , I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION 4.O O C AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY O O O WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMe, MERE BY CERNG AND TIFY THATS. OPENLY REGISTERED AND/OR {� LICENSED AS REOUIREO LO ELES'COUNTY AND STATE OF 12. 13-7 " CALIFORNIA OR THAT IA HE GA OWNER OF,AND INTEND TO RE- _ SIDEIN.THEABOVEDE RIB RE ID NTIAL PROP E RTY, SIGNATURE ' OF PERMTCTEE WORKERS'COMPENSATION DECLARATION 808 ((280) CE APPLICATION FOR PERMIT {I CE 80 �J I hereby affirm that 1 have A certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800. Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. Company ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING N � STATION DEPTH F] Certifiedcopy k filed with the county building inspection ADD.Ess _ UPPER department. LOCALITY � r Mq NHOLE REFERENCE LOWER Date Applicant NEARESTTYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. p/yy�m {�}"p - Y. CURB P.L. M.L. TO F.L. COMPENSATION INSURANCE / �/ F.C. RD. OWNER t e�Jr Co. IMP. NO. l0. NO. 1 (This section need not be completed if the work involved MAIL ADDRESS / i TRUNK PERMIT NO. ROAD PERMIT NO. >_ by the permit is for one red dollars ($100) or less.) �� D�� AFFIDAVITIN ASCMENT RECORD. INSTR. N DATE O CITY / / TEL. NO. 1 certify that in the perf m- c f th work for whicl his LEGAL U permit is issued, I sh rt y a person in any an tier DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become sr fe t th or r ' m on Laws. Q BLOCK TRACT STATE ENCROACHMENT F• Date Ap c NO. OF BLDGS. PERMIT NO. f..) SIZE OF LOT NOW ON LOT W NOTICE TO APP ANT: If, after making this Certificate of d Exemption, you should become subject to the Workers' USE OF N Compensation provisions of the Labor Code, you must forth- Bm LDlrves q CHARGES Z with comply with such provisions or this permit shall be CONTRACTOR Ce / CONNECTION CHARGE FEE deemed revoked. LICENSED CONTRACTORS DECLARATIONgDORE55 / REIMBURSEMENT FEE I hereby affirm that I am licensed under provisions of Chapter ^� ,y DISTRI=T nD. RDu OK MAI PC IT 9 (commencing with Section 7000) of Division 3 of the Busi- crtv • EL, rvo. f/Y� f//r�) Bess and Professions Code, and my license is in full force and STATE Llc. ] LICENSE NO. ID CLA 55 / (O effect. ) No. DESCRIPTION OF WORK FEE FINAL I '� 1 VALIDATION License Numb r`�G Lie.Class / R ewe RAGE PIT R DATE 3 1 Z—S�' rs5 ND/09 D Contractor Date OHOUSE SEWER CONNECTING O FINAL ❑ PRIVATE DISPOSAL SYSTUM G.DR BY ' c— I en exempt from the licensing requirements as I am a licensed architect or a registered professional engineer Dose 5EWER�D acting in my professional capacity (Section 7051, Bus- OVERFLOW se EPAGE PIT.DR iness and Professions Code). EXTN. DRYWALL. BLL AMNH OLE ALTER, REPAIR OR DON HOUSE SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNER'S Permit f I License Law for the following reason (Section 7031.5. Busi- AUTHORIZATION TOTAL FEE Bess and Professions Code): I HAVE AT THIS DATE Ff.] DNaoaET W 23963A I ' l- as owner of the property, will do the work and the *o THEOPUBLIC SCWER TC / �� r �/ � ECLIaC -7 structure is not intended or offered for sale Section / /�f� G/{ ( SIGNED THIS H V OFyy19 J # D ° ° D 1 O 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY Dens _ P ° ° I:00 I hereby affirm that there is a construction lending agency for the performance of the work F r which this permit is D R zs .o'o o (f U O U issued (Sec. 3097,Civ. : p y..�r /� Q 9 Lender's Name CSI f ) /7 u-y- L(�. / 5 r+ 0 J 0Z0rJ—a1 Lenders Address I certify t t lave read this application and state that the above inf ma u n is correct. 1 agree to comply with all County ordinanc a d ate lases regulating Plumbing and Sewers, and hire y I ixe representatives of this County to enter opo tl ab v n nt Red pro rty for inspection pur Uses. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date `�