HomeMy Public PortalAbout5402 LOMA AVE_Sewer__ DEPARTMENT OF COUNTY ENGLNF-ER SEWER=SEWAGE DISPOSAL
'DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER 1�I BUILDING 541 I C) , �CMa. Ave,
ADDRESS J-�
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
SS `, rfoA O 'LOM/ADDREAVei.
CROSS ST. 1 v
LOCALITY %;—m P Je— C 17% DISTRICT NO SERIAL NO. l QPEERMMIIT NO.
NEAREST /�� I ✓Q A 1 — � S
CROSS ST.
II-. RECEIVED BY Ready for Inspection DATE ISSUED
OWNER l ii1 A-S G/g-it to 0 y,-r e )--so
MAIL ADDRESS S eo /A/c � O )o A- /�(/G USE ZONE OCCUPANCY BK MAP PG
CITY /eDIa. C 17-11 TEL-NO. 47! a �1 Z��.. D—
CONTRACTOR CO.IMP.NO. rl 1
ADDRESS
JOB.N0.
CITY TELAO. TRUNK PERMIT NO. �—
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT N0. PERMIT NO
BLOCK�,A ,'TRACT '2796 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT �i N0.OF BLDGS.
NOW ON LOT ,�a/ CHARGES
USE OF j CONNECTIO RGE FEE
BUILDINGSK v _
NO. DESCRIPTION OF WORK FEE _T REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO ••-tea
PUBLICSEWER @ $ 3.50 J RECEIPT NO. D I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING f`0 I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00- ( A!J Jj AREFERENCE
� LOWER
TYPE OF ECTIOMEL THPFROM 7
OWNERS PERMIT ; I 1 00
AUTHORIZATION I TOTAL FEE a
NAED
CONTRAC O1R TO CONNECT THE ABOVE D SCRIBEDDATE CONTRACED WITH THEI EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS____-_-._......DAY OF...._._. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.................... _.._...._._.. BUILDING OR WORK
r._.._.._.._.........____.
SEPTIC TANK,SEEP.PIT(S)
ADDRESS------_..._----•-•-.•-••--•--•--...--.._.. AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL I] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. t SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT/I%AM THE LEGAL OWN-
ER OF THE ABOVE qESCRIBECI RESIDENTIAL PROPERTY. BACKFILL SEPTIC-TANKS
SIGNATURE SEEP.PIT(S)[] CESSPOOLS Ej
OF PERMITTEE-- —•----- -----------
76A642A 663 7/53
76A642D - �I
CE 8081REV 6/781I AkPPL1. OCA` A 8®N•.[�'®[� ®��� 0-�- 1 `I -
SEWER - SEWAGE DISPOSAL.
COUNTY OF•LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO ILL IN :�a
OUP MAP r ESSED BY
BK
` BUILDING
ADDRESS O
f CO VECTION DATA
LOCALITY .i
NEAREST ..� STATION I DEPTH
• CROSS ST , - UPPER
rZ _� MANHOLEREFERENCE LOWER
OWNERAl TYPE OF CONNECTION LENGTH FROM
ML TOPL 1
MAIL Y CURB PL '
ADDRESS
' PC NO
CO IMP NO JOB NO `
'CITY TEL NO
LEGAL TRUNK PERMIT NO ROAD PERMIT NO -
DESCRIPTION i LOT NO ,
, AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
I BLOCK TRACT
' NO OF BLDGS �/ •
SIZE OF LO NOW ON LOT HWY OR ST WIDENING
USE OF
BUILDIN ,9 STATE ENCROACHMENT
PERMIT NOINDUSTRIAL
CONTRACTOR/ WASTE APPROVAL
• ADDRESS CHARGES
f CONNECTION CHARGE FEE
CITY TEL N
STATELIC REIMBURSEMENT FEE
LICENSE NO CLASoc— p
NO DESC PTION OF WORK FEE APPROVALS DATE INSPECTORS SIGNATURE C�
HOUSE SEWER CONNECTING TO
PUBLIC SEWER-
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK SEEP PITIS)
CONNECT ADDITIONAL BLDG OR
OUSE SEWER AND/OR DRAINFIELD -
OVERFLOW SEEPAGE PIT,-DRAINFIELD CESSPOOL ❑ DRYWELL Cl
EXTN,CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE ALTER,REPAIR SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND ,
• ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑ - - -
OWNERPermit SEEP,PITIS)El CESSPOOLS
❑
'S s
AUTHORIZATION TOTAL FEE2j
VALIDATION'
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING /j�rylijl.v( 'ca�'•)�a�fril
TO THE PUBLIC SEWER
SIGNED THIS OWNER OR99' DAY OF//�'�� >-? vV Al. 7 9(p3 - • - 1516-7-A
OWNERS AGE ul _ VO/ _Z_ # ��O.
0 O'O o
ADDRESS
14,
• I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - 42 D O 00
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL UNTY ORDINANCES AND STATE LAWS REGULATING Loop!O n J
PLUMBING N SEWERS _ - -- - �O O.O 4� V F
I HER BY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENS AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF O ,♦ _ y
^
CALIF NIA OR THAT I AM THE LEGAL OW R OF AND INTEND TO Rc E- -_
SIDEI ,THE DESCRIBED D IALP PERTY
SIG NA UR - -
OF PE MITTEE