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HomeMy Public PortalAbout9178 LAS TUNAS DR_Sewer__ ^E-663 11.55 8 - APPLICATION FOR PERMIT 1 &E•66a DIVISION OF BUILDING AND SAFETY 5 EW E R-SEWAGE D I S POSA L Department-of County Engineer - County, of Los;Angeles BUjI,LOING ` ` JOHN A', LAMBIEY, COUNTENGINEER ADDRESS ®,�,i",�• CASSATT'D;,GRIFF_JN_..SUP'r-pF,By!Lo1Nc LOCALITY ! ' 'FOR A�PPLICANkT TO FILL-IN"�� cRC sr. ` "17''JLEGAL I.DESCRIPTION. e'LOT N0.• OWNER d BLOCK TR a. A • - - MAIL ADDRES " CT .NO. OF BLDGS F SYZE OF LOT ,NOW ON LOT CITY ,� TEL. NO USE OF - BUILDINGS DISTRICT NO - GROUP I -EK MAP PG CONTRACTOR CONNECTION DATA ADDRESS STATION // DEPTH (rL CITY TEL. N0. — +MANHOLE REFERENCE _ UP_P_ER gj- TATE I J I /LOWER REGISTRATION NO / Q ❑ COUNTY NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TOY. CURB P L M.L TO P.L. PUBLIC SEWER @ $3 50 J SEPTIC TANK,SEEPAGE PIT OR - PITS AND/OR DRAINFIELD @ $3 00 OVERFLOW SEEPAGE PIT,DRAINFIELD 'Y.�S Q, P. C N0. EXTN .CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO. ! —f/ JOB NO HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL'SYSTEM @ $1 00 -TRUNK PERMIT NO ROAD PERMIT NO. CONNECT ADDITIONAL BLDG OR ;STATE ENCROACHMENT, WORK TO HOUSE,SEWER @ $1 00 `PERMIT NO ALTER,REPAIR OR ABANDON HOUSE _ INDUSTRIAL SEWER OR DISPOSAL SYSTEM @ �$1 00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE ,r7� OWNER'S PERMIT- $ 1 00 � AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE FHAVE AT THIS DATE A CONTRACT WITH THE HEREi`NrrAME) CON. APPROVALS DATE INSPE TOR'SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO IHE'PUBLIC SEWER - NEW HOUSE SEWER "pA sa SIGNED,THIS DAY OF 19 CONNECT ADDITIONAL OWNER OR . BUILDING-OR WORK OWNERS AGENT - SEPTIC TANK,SEEP, PIT(S) ADDRESS - AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE-READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND STATE ,THAT THE ABOVE IS' CORRECT AND AGREE TO COMPLY ._ WITH ALL COUNTY ORDINANCES AND ,STATE LAWS REGULATING ALTER, REPAIR,SEWER OR L BING,AND SEWERS SEWAGE DISPOSAL SYSTEM EREBY'CERTIFY THAT A 'AMS PROPERLY REGISTERED -AND/OR DISCONNECT PLUG AND SED` AS REOUIRED BY,LOS ANGELES COUNTY AND,STATE OF ABANDON HOUSE SEWER ORNIA OR T,HAl_I,AM, T LEGAL OWNER -OF THE -ABOVE- - - IBED RESIDEN?IAL- __ '- BACKFILL SEPTIC TANKS❑ SEEP PITS) ❑ CESSPOOLS❑TPURE,.ERMITTEE 'y_y '�-�•='+- - ' JOFi'N'4',"LAMBIE"C UNTY ENTGINEER ''� VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR CK N 0 CASH y1 �,13>" 14 '1R - JUL23 10 A 4.50 M G42D,D_82 76AAPPLICATION FOR PERMIT 78A 84 COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST LEGAL DESCRIPTION LOT NO OWNER (,V MAIL r BLOCK TRACT C�(J , ' ADDRESS7f A5 r / "S NO OF SLOGS SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP MAP 70CESS IF AP BK PG CONTRACTOR o �©!\ ADDRESS / C�p V CO ECTION 9ATA CITY TEL NO STATION DEPTH E UPPER REGISTRATION NO` 4rCOUTATNTY MANHOLE REFERENCE LOWER a NO DESCRIPTION OFf WORK FEE TYPE OF CONNECTION LENGTH FROM O HOUSE SEWER CONNECTING TO Y CURB P L M_L TO P L V PUBLIC SEWER @ 55 00 SEPTIC TANK,SEEPAGE PIT OR P C �/ PITS AND DRAINFIELD SIO 00 CO O NO O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM Q S3 00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT wl1IYEn EASEXENT RECORD INSTR NO DATE d WORK TO HOUSE SEWER @ $300 h OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN'CESSPOOL,DRYWELL MANHOLE @ $5 00 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ 33 00 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVA _ OWNERS PERMITS z 00 L41CH GES CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE OZ7 IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC 5EW R //^^ --4APPROVALS DATE INSPECTOR'S SIGNATURE 0 SIGNED THIS_� DAY OF —0_/ 19 OWNER OR NEW HOUSE SEWER _ OWNERS AGENT A , - CODDITIONALI+y BULDING OR WORK ♦- aE ADDRESS ILDING � r SEPTIC TANK SEEP,PIT(S)' I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD ' AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA R THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOVE DE RIBED �IOENTIAL PROPERTY ABANDON HOUSE SEWER SIGN ATU ❑ OF PER BACKFILL SEPTIC TANKS SEEP,PIT(5) ❑ CESSPOOLS ❑ ALIDATIOROBERT WOOD CK M o cnsH SUPERVISING MECHANICAL ENGINEER LAAO 3 5 69-0 DEC 16 1 0 D 5.0 0- WORKERS' COMPENSATION DECLARATION hereky affirm that I have a certificate of consent to self { nsure, or a certificate of Workers'Compensation Insurance, or 78A642D certifi.sd copy thereof (Sec 3800, Lab C ) 92-0002 DPW 6/88 APPLICATION FOR PERMIT Policy--No Company Q Certified copy Is hereby furnished SEWER - SEWAGE DISPOSAL ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY U department Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING U LDDIN ;/7 STATION DEPTH COMPENSATION INSURANCE !! (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 �� C 1 T? LOWER I certifythat In the performance Of the work for Which This NEAREST t TYPE OF CONNECTION LENGTH FROM p CROSS ST r•Cf-+ Y CURB p L M L TOP L permit Is issued, I shall not employ any person in any manner �r PC NO so as to become subject to the Workers'Compensation Laws OWNER CO IMP NO JOB NO Date Applicant AD MADILRESS � c ]7_ TRUNK PERMIT NO ROAD PERMIT NO �'�J �i� NOTICE TO APPLICANT If, after makingthis Certificate Of Q AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE CITY ��/Af/7/-/L-� ( EL NO a 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 PERMIT NO LOT SIZE OF LOT NOW ON LOT I hereby affirm that I 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 effect CONTRACTOR a Z>714 �ln'�UrIYt �a�AyCONNECTION CHARGE FEE License Number LIC Class ADDRESS % M dH�k (may/ REIMBURSEMENT FEE Contractor 'Date L�/ C l'-O0 DISTRICT NO RODUP1 MAP ROCESSED BY CITY p�ce e i L NO a(E? 7 J /J�// � ' BK PG >_ ❑ I am exempt under Sec of the L A Co STATE /�/, ' / LIC ,j 2 t1 P LICENSE NO C �/ �'y CLASS C� J O Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE- FINAL U HOUSE SEWER CONNECTING TO DATE VALIDATION X B & P Code for the following reason PUBLIC SEWER T O SEPTIC TANK,SEEPAGE PIT OR FINAL J U PITS AND/OR DRAINFIELD ,r' Date BY HOUSE SEWER CONNECTING TO W PRIVATE DISPOSAL SYSTEM (L Signature CONNECT ADDITIONAL BLDG OR ( Uj WORK TO HOUSE SEWER " OWNER-BUILDER DECLARATION hereby p OVERFLOW SEEPAGE PIT, LL,MANHOLE /,j 42, ILaw affirm that I re exempt from the Contractor's License OVERFLOW ,CESSPOOL, E PIT,DL,MANHOLE C7S (/� �( INFIELD Law for the following reason (Becton 7031 5, Buesness and Pro ALTER,REPAIR OR ABANDON HOUSE tr fessions Code) SEWER OR DISPOSAL SYSTEM y ACCT-. ❑ 1,as owner of the property,or my employees with wages as 3 07 .c�) their sole compensation, will do the work and the structure - is not intended or offered for sale (Section 7044, Business Permit $ 1 ITEMS and Professions Code) OWNER'S ❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE TOTAL, :10 c licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ICONTRACTORf(J�{ CBusiness and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBL HECK 21•0CONSTRUCTION LENDING AGENCY (vHAItK]E aC{C; I hereby affirm that there Is a construction lending agency SIGNEDTHIS DAY OF for the performance of the work for which this permit Is OWNER OWNERS AGENT , issued (Sec 3097, Civ C ) ADDRESS 0O -- W01 11/14/89 1/17 V7 Lender's Name 6769 i AP! 9-34 Lender's Address I certify that I have read this application and state that the above Information Is correct I agree to comply with all County ordinances State law regulate Plumbing and Sewers, and he y t 'oreze re rise to sof th County to enter 4_�-men o ed a for I pection purposes Signature of Pe it a Date SEE REVERSE FOR EXPLANATORY LANGUAGE