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HomeMy Public PortalAbout5434 LOMA AVE_Sewer__ 2�7° 76A APPLICATION FOR PERMIT L^' 76A 642D COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION AUILO'SS JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS COLEMAN W JENKINS. SUPT OF BUILDING 7A �LOCALITYF R APPLICANT TO FILL IN 7 CROSSSST 11 a ( �� f ip A (PRINT OR TYPE ONLY) jLEGAL /� KYA DESCRIPTION LOT NO (/meqOWNER •(p� //�y�/ MAILDq •Y IBLOCK TRACT /!� ADDRESS/� (� �! � [(disNO! OFBLDGS A7_I/ lv' IK ! INSW d �'' ' SIZE OF LOT NOW ON LOT CITY TEL NO USE OF f v DISTRICT NO GROUP CLASS MAP PROLES BY BUILDINGS / f (� f _ R BK O P CONTRACTOR r• m 3s ADDRESS CONNECTION DATA CITY TEL NO STATION L3 DEPTH UPPER LO E STATE LIC MANHOLE REFERENCE R LICENSE NO, CLASS $pZ,lD NO DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L PUBLIC SEWER 00 PC NO SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ SIO 00 CO IMP NO JOB NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 3 -:?3PRIVATE DISPOSAL SYSTEM S3 00 - CONNECT ADDITIONAL BLDG OR AFFIDAVIT I W4IVII I'1151M[MT RECORD INSTR NO DATE O WORK TO HOUSE SEWER $300 (J OVERFLOW SEEPAGE PIT DRAINFIELD E%TN CESSPOOL DRYWEL L'KA NH OLE @ $50 ALTER REPAIR OR,ABANDON HOUSE HWY OR ST WIDENING O SEWER OR DISPOSAL-SYSTEM @ $300 STATE ENCROACHMENT (J PERMIT NO W d INDUSTRIAL WASTE APPROVAL z OWNERS PERMIT s 00 CHARGES CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE - t TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ Il r OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP,PIT(S) AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND+STATE O� SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AMeTHE LEGAL OWNER OF A(lrD INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOV2 DESCRIBED RESIDENTIAL PROPER Y ABANDON HOUSE SEWER SIGNATURE E�� ti� OF PER MTTTE � �// BACKFILL SEPTIC TANKS ❑ v /_ SEEP PIT(S) ❑ CESSPOOLS VALIDATION JACK R. ALLEN CK M O SUPERVISING MECHANICAL ENGINEER CASH cv LAS ' l 0 ?I-_ SEP 1 1 0 D 1 0.0'0 WORKERS',COMPENSAJION DECLARATION hereby ` ':m th 1 I have a certificate 'of consent to self Insure, or�ertlficate of Workers'Compensation Insurance, or-,.,. 'r 76A642D t a certified copy thereof (Sec 3800, Lab C ) CCE 808(REV a/at) n(inn OC n UVI® (� FOR fo�2RWT Policy No__TCompony ©s G�1lf 4�L� !�1 Vl ®p�UCI FOR I�L II�OV� ❑ Certified copy Is hereby furnished SEWER - SEWAGE MSPOSA L ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES r BUILDING AND SAFETY department Date Applicant FOR APPLICANT TO FILL IN ' CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �✓(� 2 � STATION DEPTH COMPENSATION INSURANCE ADDRESS 7 l J Lo--A section need not be completed if the work involved by the LOCALITVY�VV +V L-�- L-� MANHOLE REFERENCE UPPER permit Is for one hundred dollars ($100)or less ) `� !� 1 LOWER I certify that in the performance of the work for which this CROSSNEAREST •V� ^ i L TYPE OF CONNECTION M L TO P IL permit is issued, I shall not emp y any person In any m ner /] Y CURB P L M L TOPIL so as to become subject to the rk rs'Co ensati on s OWNER S�-V`�� ��� CO IMP NO JOB ANO Dote��- MAIL ["� 1 •1 CNS TRUNK PERMIT NO .. ROAD PERMIT NO ApphCant ADDRESS J J �/CJ NOTICE TO APPLICANT If, a er making this C@ 61 e Of CITY ` TEL NO'?—— D42 I AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE Exemption, you should become subject to the Wor e's' LEGAL Compensation provisions of the Labor code, you must forth h 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 N`Z-7- CHARGES ness and Professions Code, and my license is in full force and effect CONTRACTOR �,V\ O '� CONNECTION CHARGE FEE �S O. License Nmb�eAr. C Class ^� ADDRESS ��Z`� r� V t \\\2 ^� REIMBURSEMENT FEE u ContractotW'`C` � Date• i.— ` - CITY _ 'J L NO $�J�g�✓ I DISTRICT NO GROUP MAP PROCESSED BY � �// BK PG STATE LIC / t, E�I Q ❑ I am exempt under Sec of the L A Co. LICENSE' �tj 3 2 CLASS ��'! !/ 0 NO DESCRIPTION OF WORK FEE // (J Plumbing Code and/or Sec of the FINAL HOUSE SEWER CONNECTING TO DATE �� VALID TION Qom„ B & P Code for the following reason PUBLIC SEWER ; SEPTIC TANK,SEEPAGE PIT OR y PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO 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 (Se Cton 7031 5, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE ALI,3 Z J� A fessions Code) SEWER OR DISPOSAL SYSTEM g 5.1 ❑ 1,as owner of the property,or my employees with wages as # o;o;0 0 0 1 their sole compensation, will do the work and the structure Is not intended or offered for sale (Section 7044, Business 0 0 2 1.5 and Professions Code) OWNER'S Permit $ ❑ 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE o,o 0 2 1.5 0-6licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE'HEREIN NAMED CONTRACTOR TO w Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER 0728=•8 b CONSTRUCTION LENDING AGENCY D I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR OWNERS AGENT Issued (Sec 3097, Civ C ) ADDRESS - Lender's Name Lender's Address 1 certify that I have read this application and state that the above Information is correct I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereffentioned e repr sentotives of this County to enter upon t roperty for Inspection purposes Sign ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE