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HomeMy Public PortalAbout9684 LIVE OAK AVE_Sewer__ CEBo03-62 APPLICATION76A642D FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS / d� WILLIAM A. JENSEN, Sup't of Building7:- LOCALITY NEARE CROSS ST. OR 1�PPLICANT TO FILL IN LEGAL DESCRIPT LOT N OWNER T MAIL ACT O 0 Q ADDRESS Q o, NO. OF SLOGS. SIZE OF LOT V NOW ON LOT CITY TEL. NO. t - USE I DISTRICT NO. GROUP MAP PROCESSED BY 01 BUILD NGS BK PG CONTRACTOR .,,e eQ/1/I� 'u��• {/ �� ADDRESS _T- n, c CONNECTIONDATA /� L CITY TEL. NO. ` ION DEPTH d /\ STATEUPPER MANHOLE REFERENCE REGISTRATION NO. C-V� / �] COUNTY NO DESCRIPTION OF WORK FEE YPE OF NN TI L NGTH FRO HOUSE SEWER CONNECTING TO. Y �ltR _6. M.L.TO P.L. PUBLIC SEWER @ $5.00 C-'{.-j - P1 P.C.NO. SEPTIC TANK.SEEPAGE PIT OR V PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. AC(J PRIVATE DISPOSAL SYSTEM @ $3.00 Y CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER @ 83.00 OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL..RYWELL.MAN1OLE @ $5.00 WIDENING OR ST. +'y ALTER.REPAIR OR ABANDON HOUSE HWY. g„+^ SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPRO L f CHARGES OWNERS PERMIT $ 2 00 AUTHORIZATION TOTAL FEE C}�� CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - TO THE PUBLIC B APPROVALS DATE, INSPECTOR'S SIGNATURE SIGNED THIS ✓ DAY - 19 9 � p -1,.t, �� !!TJJ.r'p=' OWNER OR NEW HOUSE SEWER p,p OWNERS AGENT f CONNECT ADDITIONAL t "r - ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP,PIT(S) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ElDRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REG ER ED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COU?: V AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT M THE LEGAL OW2TIL F, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE A V D BED E51 ROPERT ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMTTTE SEEP.PIT(S) ❑ CESSPOOLS ALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER M.O. CASH CQ Lj&3 SSU 4zou 1e00N a s CESOB 3.62 76A642D APPLICATION. F PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE.DISPOSrLL � DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building / LOCALITY /l NEAREST F R APPLICANT TO FILL IN CR055 ST. LEGAL DESCRIPTI OT N0.. • d OWNER BL �T CTI D / •_ • 3 O MAIL ADDRESS © Q NO. OF SLOGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. USE OF BUILDINGS DISTRICT NO. GROUP- BK PG MAP PR S D BY CONTRACTO 2 iJ _e �} `� — `u- —T I ADDRES � w/ t ', CONNECTION DATA CITY /`� EL. O. C 5 AT ON J_ DEPTH // STATE MANHOLE REFERENCE PP REGISTRATION NCe— � [ J ❑ COUNTY Y _ NO. DESCRIPTION OF WORK FEE YPE OF ONNE ,fI >> LENGTH FR• M HOUSE SEWER CONNECTING TO It /P.L� M.L.TO P.L) PUBLIC SEWER @ $5.00 O SEPTIC TANK,SEEPAGE PIT OR P.C.NO. V PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. C.R JOB NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 {{{0... CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD,IN5TR.NO. `DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 dy ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING ssLL SE R OR DISPOS L SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL ' WASTE APPROVAL CHARGES OWNERS PERMIT $ AUTHORIZATION TOTAL FEE /}^�J CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED-EXISTING DWELLING TO THE PUBLIC SE /J APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 194.?_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ILDING OR WORK ADDRESS 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 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. - CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGIST ED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTYD TATE OF SEWAG E DISPOSAL SYSTEM CALIFORNIA OR THAT M THE LE AL OWNE OF, INTEND DISCONNECT PLUG AND RESIDE IN, THE A E S' RESID AL OPERTY. ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP.PIT(5) ❑ CESSPOOLS ❑ VA&Dlrff6N ROBERT A. WOOD CK M.O. CASH 'SUPERVISING MECHANICAL ENGINEER .37S6� SEP 411 D 2 5.00 � WORKERS'COMPENSATION DECLARATION I hereby*affirm that I have a certificate of consent to self 92-0002 DPW 3/87 �} iCE 808 'insure, or a certificate of Workers'Compensation Insurance, or D lul a certified copy thereof (Sec. 3800, Lab C.) oe � PP�0C A UM � FOR PERW e , Policy No. Company ®s !!/O\UIl1JI11J'pppppprr��rr�a!/!pl\1 rr���ppppplll Vl��aalll�rr��((x)1111=0/ Inn11JIL�S22IU_O///��pp U ❑ Certified copy is hereby furnished. SEWER - SEWAGE DOS O�SALE ❑ Certified copy is filed with the county,building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING o� 1 STATION / DEPTH /o? COMPENSATION INSURANCE ADDRESS v`\ UUU (This section need not be completed if the work involved by the permit ` MANHOLE REFERENCE /��• PP permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION GTHFROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. OWNER n dJ CO.IMP.NO. JOB NO. ' MAIL1 S 1•.\� /\_ e' TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS i VVcccv i S NOTICE TO APPLICANT: If, after makingthis Certificate of �p r, 31 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY CZr ` C� TEL NO. a S�P 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. 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 j. eke 4 CONNECTION CHARGE FEE } License Number LIC.Class ADDRESS REIMBURSEMENT FEE a O y�",n,B DISTRICT'NO. GROUP MAP PROCESSED BY U Contractor Dale CITY _ Fes-Vim., TEL.NO. �- �i BK PG 0 STATE UC. -� ❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS O U Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE VALIDATION W PUBLIC SEWER a B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR NAL PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION 'WORK TO HOUSE SEWER >OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, BUisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE is j fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my'employees with wages as their sole compensation, will do the work and the structure 7•__t_ I is not intended or offered for sale (Section 7044, Business y and Professions Code). OWNER'S Permit $ ❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE '�S l; licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO 1 fig' ``�' ---�»_� Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. r.:• l; - - CONSTRUCTION LENDING AGENCY •°5;_ t S F 19_DAY D THIS O IGNEIS I hereby affirm that there is a construction lending agency S +_i€�••ii;;_`w _i; for the performance of the work for which this permit is OWNER OR P p issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS 1 sr- it»i ; i Lender's Name Al.l;;,_4 �I,.I�;,� i,,i ,__• • aender�rAddrere s =a 3,1 t I ve rea this ap ication and state that theat carr t. I agr to comply with all County at aws regula ng Plu bing and Sewers, a i e representat eS oft s County to enter � ve oned prop y for in ect n purposes./ a ai SEE REVERSE FOR EXPLANATORY LANGUAGE