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HomeMy Public PortalAbout4979 LOMA AVE_Sewer__ 4200 76A6APPLICATION FOR PERMIT 76A64 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNEAREST 7SS JOHN A' LAMBIE, County Engineer L WILLIAM A. JENSEN, Supt of Building � /I/I 1. [j s FOR APPLICANT TO FILL IN G DESCRIPTION ti/LEAL ' L&\' NO �(� L OWNER �� MAIL Or BLOCK TACT �/ ADDRESS LCL7 iNOOW OF BLDGS / SIZE OF LOT /-y Z' tS NON LOT CITY TEL NO USE OF BUILD, NGB ('B / DISTRICT NO GROUP MAP (� PROCESSED BY BK pa CONTRACTOR 49 2 l"[ : N v `L. ADDRESS -�vzy Q CONNECTION DATA CITY NO STATION DEPTH El STATE UPPER REGISTRATION NO - COUNTY MANHOL EFERENCE LOWER NO DESCRIPTION OF WORK FEETYPE OFC ECTION FROM HOUSE SEWER CONNECTING TO Y CUR LE P L. TO P L PUBLIC SEWER (a 53 00 C.NO. )- SEPTIC TANK,SEEPAGE PIT OR CO IMP NO JOB NO a PITS AND/OR DRAINFIELD 510,00 O OUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U PRIVATE DISPOSAL SYSTEM $300 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EMENT I RECOR INSTR NO, DATE 0 WORK TO HOUSE SEWER ® $300 OVERFLOW SEEPAGE PIT,DRAINFIELD r EXTN,CESSPOOL,DRYWELL,MANHOLE 0 $5 00 V 'WY OR ,WIDENING UJ ALTER,yi@P�ALBrpR..A.BA#FBOTMH O U S E d HEWERAL^SY%=M @ 5300 BTA ENCROACHMENT N PE MIT NO Z INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PER $ i 00 AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED{CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANKSEEP,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 PUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ LL-ICEISEDIAS EREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,RE'PA#4 SEWER 01R REQUIRED BY LOS ANGLES COUNTY AND STATE OF ORNA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND E IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER ATURE BACKFILL SEPTIC TANKSPERMITTEE SEEP.PITS) ❑ CESSPOOLS ❑ VALIDATION ROBERT A. WOOD CK M O CASH SUPERVISING MECHANICAL ENGINEER `ACC 8 8 2TJAN17 7 1 o D 5.0 0- 11 � 76A 642D-CE808 A-7/76 Y PP OC =TOON FOR P2R❑ O I SEWER--SENAGE DISPOSAL � I lul -COUNTY OF LOS ANGELES c DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FOR APPLICANT TO FILL IN /^ 4., DISTRICTTNN/O�/ GROUP BK MAPPS S$ED BY BUILDING \ - ADDRESS LOCALITY G,s -- CONNECTION DATA NEAREST / STATION ��/I DEPTH PIPER CROSS ST MANHOLE REFERENCE OWNER l/1//r�.�I A� � ��f{- / of TYPE OF CONNECTION l/ LENGTH FROM MAIL 7 !D a Y CURB L` M L TO P L • ADDRESS A,r�lli L f4 � y PC CITY jVi (/ NO I G CO IMP NO .10BN �-� LEGAL r OY • TRUNK PERMIT NO ROAD PERMIT NO DESCRIPTION LOT NO '� �. AFFIDAVIT wuv[It I [A5[M[xr RECORD INSTR NO DATE BLOCK TRACT �/ NO OF OLD GS SIZE OF LOT NOW ON LOT HWY OR ST WIDENING USE OF STATE ENCROACHMENT BUILDINGS PERMIT NO s y INDUSTRIAL, CONTRACTOR WASTE APPROVAL a ADDRESS CHARGES V j CONNECTION CHARGE FEE CITY TEL NO STATE LIC REIMBURSEMENT FEE LICENSE NO GLASS U, NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE III £� HOUSE SEWER CONNECTI PUBLIC NG TO ��'1 I CL SEWER (/ NEW HOUSE-SEWER SEPTIC'fANK SEEPAGE PIT OR PITS AND/ORAD RAINFIELD CONNECT ADDITIONAL , HOUSE SEWER CONNECTING TO BUILDING OR WORK PRIVATE DISPOSAL SYSTEM SEPTIC TANK SEEP,PIT(S) CONNECT ADDITIONAL BLDG OR AND/OR DRAINFIELD ' WORK TOHOUSE SEWER - OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL Q DR-YWELL ❑ EXTN CESSPOOL DRYWELL MANHOLE ALTER REPAIR SEWER OR ALTER REPAIR OR ABANDON HOUSE SEWAGE DISPOSAL SYSTEM SEWER OR DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER L BACKFILL SEPTIC TANKS :14&_ SEEP PITIS) ❑ CESSPOOLS OWNER'S Issuance Fee s fs� I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AUTHORIZATION TOTAL FEE ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 71' `}VK, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- PLUMBING AND SEWERS TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING y� + I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR a TO THE PUBLIC SEWER LICENSEDAS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SIGNED THIS DAY OF I9_ CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO OWNER OR RESIDE IN THE ABOVE DESC ED RESIDENTIAL PROP TY -6WNERS AGENT } SIGNATURE OF PERMITTEE ALMATIO CK M O. HH 1 5.0 0 76A64 4/72 A ZL I C A N FOR p R M I T 76A642L P'� /'1 �tl r`( r f'C�V� G COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS LOCALITY ax- NEAREST FOR APP LICA T TO FILL IN CROSS STLEGAL / AA ff. G r/A/ /?/f- DESCRIPTION LOT NO OWNER t� � / G/�� MAIL K TRACT A BLOCDDRESS FiJ Q��J!"i SIZE OF LOT NOWNO OO NB LOTS CITY���I'le Gf TEL USE OF I DISTRICT NO GROUP MAP *PRO C SSE BY BK BUILDINGS CONTRACTOR �o ML cif �sr v``� .. ' ADDRESS ) CONNECTION DATA CITY !j/'�'_ EL NO 7/ �2?6 STATION DEPTH STATE / LIC �� MANHOLE REFERENCE UPPER LICENSE NO52g, CLASS LOWER NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TOY CURB PL M L TOP L PUBLIC SEWER } SEPTIC TANK SEEPAGE PIT OR PC NO d PITS AND/OR DRAINFIELD @ CO IMP NO JOB NO O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V PRIVATE DISPOSAL SYSTEM CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I CASEMENT RECORD INSTR NO DATE O WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT DRAINFIELD V EXTN CESSPOOL ORYWELL MANHOLE @ W ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING d SEWER OR DISPOSAL SYSTEM @STATE ENCROACHMENT Z PERMIT NO I INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT s CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE �' IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE gBOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEW;�A✓ APPROVALS DATE IN PECTOR'S SIGNATURE SIGNED THIS�J�.DAY OF L����1r� 1g OWNER A - o/ • _ 6/ NEW HOUSE SEWER y OWNERS AGENT +yaw.a-)� Q _ir�Pw'refer`— CONNECT ADDITIONAL ADDRESS BUILDING OR WORK I HEREBY ACKNOWLE GE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S) 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 D ISPOSAL SYSTEM CALIFORNIA THAT I AM THE LEGAL OW OF AND INT NO TO DISCONNECT PLUG AND RESIDE IN T BOV RIBED RESI N IAL PRO RT ABANDON HOUSE SEWER SIGNATURE ❑ OF PERMIT BACKFILL SEPTIC TANKS SEEP PITIS) ❑ CESSPOOLS ❑ VALIDATIPW CK M O, CASH l ' 03OL�v �.5i ® 15.00. ew11� WORKERS'COMPENSATION DECLARATION' �I hereby''affirm that I have 6 certificate'of consent to self I nyuie, qr a certificate of.Workers'Compensation Insurance, or 78A642D µ a certified copy,thereof(Sec 3800, Lob C ) 82-0002 DPW 6/68 a[�pdOCA i�90o [,�J ©R PL 6�G��4 Pal+gyV No• Company ElCer{ifiea,copy Is hereby furnished SEWER SLEWAGE WSPOSAL , ❑ 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 —7C� L C�L.� AA,,-- STATION f 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 t, �Q I certify that in the performance Of ilia Work for which this NEAREST r `^ TYPE OF CONNECTION LENGTH FROM , I YL� Y CURB PL ML TOPL permit Is Issued, I shall not employ any person In any manner , so as'to become subject to the Wor 6rs'Comp e tion Laws J c NO / /• OWNER CO IMP NO JOB NO / �'� •-�� ! /� q MAIL 0<- Date-6— -�! TRUNK PERMIT NO ROAD PERMIT NO Date/,Cte' "-S/VJ CCA--WD/pl scant _ L ADDRESS • 7!2 C ��y V`` - �,r AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO If DATE NOTICE.,TO APPLICANT If, after making this Certificate Of CITY TEL NO r� '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 complyl,with such provisions or this,permlt shall be deemed revokedBLOCK 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 provisioris of Chapter USE OF 9 (commencing with Section 7000) of Division Sof the Bus, BUILDINGS CHARGES ness and Professions Code,,and my.license is in full force and effect CONTRACTOR• ' CONNECTION CHARGE FEE License Number LIC.Class - ADDRESS REIMBURSEMENT FEE Contractor Date '' DISTRICT NO GROUP MAP. PROCESSED BY q�q CITY „ TEL NO, BK PG• a STATE LIC ❑ I am exempt under Sec df the L A.Co LICENSE NO CLASS � a Plumbing Code and/or Sec - of the NO DESCRIPTION OF WORK FEE � FINAL Q.+ HOUSE SEWER SE R CONNECTING TO DATE VALIDATION 0) B 8 P Code for the following reOSOn SEPTIC TANK,SEEPAGE PIT OR 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 I hereby affirm that I am exempt from the Co'ntractor's LicenseOVERFLOW SEEPAGE PIT,DRAINFIELDEXTN,CESSPOOL,DRYWELL,.MANHOLE- Law for the following reason (Secton 7091 5, BuisneSS and-Pro- ALTER,REPAIR OR ABANDON HOUSE n61nS Code) SEWER OR DISPOSAL SYSTEM'as owner of the property,or my employees with wages as eir sole compensation, will do the work and the structure is not Intended or offered for sale (Section 7044, Business ;� and Professions Code) _ OWNER'S Permit $ 6� " i I TENS ❑ I,.as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE e° —° licensed contractors to construct the ro ect Section 7044, TO _ {'i l-' -'50 . • P I ( I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONT ACTOR TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER' - CHECK'. y ' L-'-I•°�� CONSTRUCTION LENDING AGENCY r ' I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ CHH! _ °I P for the performance of the work for which this permit is OWNER OR ` issued (Sec 3097, Cry C ) ' ' OWNERS AGENT ' Lender's Name ADDRESS s _ i;J—i?3I(_f +;,•'_�:'7� Lender's Address i`•�, I' �it L C'° I certify that I have read this application and state that the above information Is correct I agree to comply with all County ord+na 1ceS and State laws-regulating Plumbing and Sewers, and eieby author ze)representatives of this County to enter uPon above- a Toned property for Inspection purposes �X7 �� �.�� ~�/ , Slgnatture of Perm itteeO Date SEE REVERSE FOR EXPLANATORY LANGUAGE