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HomeMy Public PortalAbout6019 LOMA AVE_Sewer__ a4 _ p� p yp ppg�y p�a�, ��yq qqs� gq{�pgp�p�y V76 A642D �tom'P q 'CAT I O N ■ ®R' 'Y.- 9vm ! •MIT b'g■ 5&E-663 12.54 Y 9 i L O`Y ■'. DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D 6 S PO SA L ' Department of County Engineer Im County of Los Angeles ADRESSG f /� L 0/fj¢ �F WM. J. FOX. COUNTY ENGINEER 7-7 CASSATT D. GRIFFIN,-SUP'T'OF'BUILDING I J, +LOCALITY FOR APPLICANT TO ILL.INceoss sr. .LEGAL -..�. DESCRIPTIO - OT,NO. •_��4•"D ` OWNER BLOCK. 'TRAOTQ � MAIL ADDRESS_C/00/'2! 777 NO. OF BLDGS. SIZE-OF LOT NOW ON LOT 4 CITY Thr Lr. %y TEL. NO. I USE OF BUILDINGS DISTRICT NO. GROUP MAP ' CONBK_ PGTRACTOR- _ �. I. I 7/ ADDRESS CONNECTION DATA CITY- STATION (�� & DEPTH ' .❑ STATE �q / / - MANHOLE REFERENCE REGISTRATION N0. - X� C ❑ COUNTY - V� •7 /V '+HWQR LOWER TYPE OF-CONNECTION LENGTH FROM ® or No. DESCRIPTION OF WORK FEE CURB fir. M.L.TO P.L. T HOUSE SEWER CONNECTING TO /® PUBLIC SEWER tt $ 3.50 _t9 HOUSE SEWER CONNECTING TO - _ PRIVATE DISPOSAL SYSTEM 1.00 •CONNECT ADDITIONAL BLDG. OR CO. IMP, NO. y / -JOB. N0. WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING .SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. DISCONNECT AND ABANDON SEWER •• STATE ENCROACHMENT -AND/OR DISPOSAL SYSTEM '1.00 PERMIT NO. SEPTIC TANK, SEEPAGE PIT OR - PITS AND/OR DRAINFIELD 12.00 INDUSTRIAL CESSPOOL- URYWELL - WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CHARGES PERMIT CONNECTION CHARGE FEE OWNER'S S 1 Oo" AUTHORIZATION-. TOTAL FEE'- 'REIMBURSEMENT FEE TRACI`ORTTOS CONNECT THEACTEDABOVE DESCRIBED EXIITH THE ESTINGAMED -CN-DW ELLO G APPROVALS ` DATE INSPECTOR'S SIGNATURE TO THE PUBLIC"SEW R- - - --` — ♦`, , NEW HOUSE SEWER SIGNED THIS DAY OF r. 'OWNER OR - CONNECT ADDITIONAL; - - --- -- - ---•' OWNERS AGENT BUILDING OR WORK SEPTIC-TANK,-SEEP, PIT(S) - - - -- ADD@ESS •- - AND/OR DRAINFIELD -' I HEREBY ACKNOWLEDGE THAT I HAVE READ. THIS APPLICATION CESSPOOL[:1 DRYWELL.❑ ' AND STATE-THAT THE ABOVE IS CORRECT AND AGREETO COMPLY - - WITH ALL COUNTY ORDINANCES AND'STATE LAWS_REGULATING - ALTER,`REPAIR;.SEW ER OR PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT'I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND • LICENSED'AS•REC•UIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALf,FORNIA'-,OR-THAT: I AM THE LEGAL OWNER OF THE BOVE DESCRIBED RESIDENTIAL PROPERTY: BACKFILL SEPTIC NKS❑ ry>>g9 / ! "SEEP:PITS)-O CESTASPOOLS' SIGNATURE - - - OF PERMITTEE WILLIAM,J. FOX,-COUNTY ENGINEER VALIDATION 10 2'8 t ` FEB BY 0 X4..5 O . .m �_ BY _ DEPUTY DEPUTY BY. BY ((// "® DEPUTY - DEPUTY COUNTY LOS ANGELES ,- ���/��_SEWAG' � ®I.SP®SAL DEPARTMENT,OF COUNTY ENGINEER, BUILDING AND SAFETY DIVISION " ADDRESS " JOHN A..LAM M County EngineeruOF ,. CASSATT D. GRIFFIN,Spt of Building 'LOCALITY 'NEA 'ST FOR .APPLICANT TO FILL'IN CRosS sT LEGAL.' .` OWNER DESCRIPTION LOT NO' _ ��+� BLOCK < TRACT ;MAIL G� 'ADDRESS' 71 NO.,OF'BLDGS. - SIZE OF LOT NOW ON,LOT CITY TEL.NO.. ' USE OF z: BUILDINGS DISTRICT.NO.J.GR.00UUPT MAP PROCESSED B BK PG CONTRACTOR ` / I ADDRESS CONNECTIO DATA CITY TEL.N0. .a -STATION - - •- ,, DEPTH - - - - STATE UPPER MANHOLE REFERENCE REGISTRATION N0. ' COUNTY LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING.TO PUBLIC SEWER ..a $3.00 - - SEPTIC TANK,SEEPAGE PIT OR' - TYPE OF CONNECTION LENGTH FROM PITS AND/OR DRAINFIELD @ $3.00 Y. CURB 4.L. M.L.TO P.L.- OVERFLOW SEEPAGE PIT,DRAINFIELD - EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 ~ -HOUSE SEWER CONNECTING TOP:C. NO. PRIVATE.DISPOSAL SYSTEM - @•-$1.00 CO.IMP.No. JOB NO. CONNECT ADDITIONAL BLDG.Olt TRUNK PERMIT NO. ROAD PERMIT N0: :WORK TO HOUSE,SEWER @ $1.001-. ALTER, RE #A QQ"tB�N00WHOUSE• STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM f� $1.00 'PERMIT"NO. >� INDUSTRIAL WASTE APPROVAL' . CHARGES Ovimis PERMIT $ 2 X500 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE - d.0 REIMBURSEMENT FEE J I•HAVE AT THIS DATE A CONTRACT WITH THE HEREIN.NAMED CON. APPROVALSDATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT-THE ABOVE DESCRIBED EXISTING-DWELLING f TO THE PUBLIC SEWER. j SIGNED THIS DAY OF 19- NEW HOUSE SEWER / OWNER OR - - ;CONNECT ADDITIONAL OWNERSAGENT BUILDING OR WORK ' S -SEPTIC TANK,SEEP,PIT(S) , ADDRESS - .AND/OR.DRAINFIELD, ` I,HERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT'THE ABOVE IS CORRECT 'AND AGREE TO COMPLY CESSPOOL❑ -DRYWELL❑ -WITH -ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES.COUNTY AND-STATE OF ABANDON HOUSE SEWER CALIFORNIA OR TH4Tj AM THE LEGAL 0 OF THE ABO E DESCRIBED RESIDEbrrIAL PROPERTY. J BACKFILL SEPTIC TANKS[:1L� SEEP. IT (S) ❑ CESSPOOLS SIGNATURE ❑ -OF PERMITTE ®s ALIDATION .'ROBERT A.WOOD SUPERVISING MECHANICAL ENQINSER �, - . - WOP .RS'COMPENSATION DECLARATION ; "L:hereby affirm "'at I have a'certificate.of consent to self " y gore or a cerri ate of Workers"Compensation Insurance; or ieAaa2D 'a certrfie'rd,copy thereof,,(Sec 3800„Lab C[) cE ® ®®qpp pw�® ��epr ��®ry ypa 808{REV 8/8T) P® �:I�rN IY I,OLI® .: 0, ��/.ill C ,. Policy No Compony. ©s Certified copy is hereby furnished SEWER-:-- SEII!/e�GE: ®ISPOSAL, Certified copy,is,filed with the county building nspec ion ; CO,U.N T, Y OF LOS ANGELES BUILDING-AND SAFETY - department. Date' Applicant FOR APPLICANT.TO FILL'IN r CONNECTION DATA ' CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING 'CO"MPENSATION'INS .ADDRESS URANCE 7'. � L'Ls✓ --- • _ `- - •, STATION DEPTH l (This se"ctjon need nbt be completed if.the.work'involved byhe �' UPPER permitt'is for`one hundred dollars ($100)or".less.) ' _* iocAurYLOWER ` e' ,„ ;v .-.; - , ,. _ .NEAREST; n NHOTYPE OF,CONNECTION LENGTH'FROM - .. _ s _ . I certif •'that in the erformance of the.work'for,which this Me y P cRoss sr_ . permit-is issued; I shall not-employ any,person'in any manner Y � � CURB;.-'� P L. 'M L TO P L': so as'to"'become•sublecfto•the Workers'-Compensa,tion.L s. P.C.No �/C ,. -. ,_R " OWNER .,.j:. 1' ,/ - ,':: '.f'/ C✓ CO IMP. NO JOB'NO.. fJiAIL .- (/ `• Z. ° d , TRUNK"PERMIT NO; .: 'ROAD PERMIT NQ_a Date d APAlicant ,fJ,tp. FT". z/�y �n �� V[.F G/1 DDRESS' 6 ' ( ( '�I�y.�^'` .-' •AFFID_AVIT WAIVER EASEMENT RECORD.'INSTR.NO.-' DATE' - NOTICE.TO APPLICANT: If, after- making,;this. Cec ficoje of CITY. TEL No. -� ': �V Exemption, you: should become subject-,:to- the WorkersLEGAL Compensation provisions.,of the Labor code;,you must forthwith' DESCRIPTION LOT NO:. fiWY:OR ST.WIDENING' - comply with such, provisions or,this permit 0all be deemed ' revoked- 'BLOCK -TRACT -.. .: STATE ENCROACHMENT- A... � .. - �. _ PERMIT NO - NO..;OF BLDGS. LICENSED CONTRACTORS DECLARATION I SIZE OF LOT NOW ON LOT - I hereby'affirm that 1,am Licensed,under,provisions of'Chapter r use OF 9.,(commencirig with"Section,7000) of Division 3'lof the Busi BUILDINGS �( " �- , �� -,CHARGES _ Hess an'&Professions Code, and my license is in full force an_d effect.". - - ' - - - - ,,. _ CONTRACTOR '- CONNECTION.CHARGE FEE_ ' 1icenSe.Number /Lic Class p - ' REIMBURSEMENT FEE' ADDRESS' ,. _ - O DISTRICT�NO.- GROUP 'MAP f PRO D ,. '.Contractor - ' CITY Date � STEL NO' .�� '" V STATE rt PG Z I am exempt under'See. of the L:A.Co. .:, ucENSE No: ciAss C V 0 ' C SEY Plumbing Code and/or Sec. of.the FINAL NO. -DESCRIPTION OF WORK FEE ~ .. - .: IN LU HOUSE SEWER CONNECTING DATE • PUBLIC SEWER B. & P Code„for the following reason C VALIDATI - SEPTIC TANK SEEPAGE PIT OR ,FINAL .� ' ' Da1e _ ' °PITS:AND/OR DRAINFIELD_ _'.BY _ - ,.,. - HOUSE,SEWER CONNECTING TO - - PRIVATE'DISPOSAL SYSTEM-��--•- - �' : '!/, .. - y t Signature ' ' CONNECT ADDITIONAL BLDG.-Q& n / OWNER-BUILDER DECLARATIOWN, ORK TO HOUSE SEWER: i' - OVERFLOW.SEEPAGE PIT,DRAIN ELD d I hereby-affirm that I am exempt from the.Contractor'S License'. EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason,(Becton 7031,:5 Buisness and Pro- ALTER;REPAIR.OR ABANDON,HOUSE' r fessions Cade):. .• .•,`.. SEWER'-OR DISPOSAL SYSTEM 82 3'3'A' - 1, as owner of the property,,or my employees,with wages as 'their sole'compensation;will do-the work'and the structure is not intended or offered for.sale”(Section 7044 Business- el #.'>o 10 { wand Professions Code). 'OWNER'S, —✓� U .t . P 'mit I;as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL,FEE ;�'(1 _, , licersed.contractors to'constru'd the protect:($ection 7044; 1 HAVE AT,THIS DATE ACONTRACT WITH'THE"4HEREI N!NAMED',CONTRACTOR TO, 1'V" 2 fes •Code). .' - _ ,' , •CONNECT THE•ABOVE:DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. 1.5 Business'and Prof ` CONSTRUCTION LENDING,AGENCY 0 2 8 4 8 7 1 hereby affirm •that there is"a'construction..lends-ng agency ' SIGNED THIS+' DAY OF • 19 for the. performance:Of the, work'foo.which'this-permit is` ' OWNER OR - ,( - • - issued (Sec.`3097, Civ.'C.). OWNERS AGENT ,ADDRESS.+• ". ..- Lender's'Name• Lener%Addr dess „ ' I certify that. I- have read this,application and'. state, that the it above'information is correct. I agree to comply;with.011'County -" - 'ordinances'and State laws regulating Plumbing and-Sewers, and hereby authorise'representatives'of'ttiis..County to enter upon'th ,abo've-men,/tJ'on�ed�property for inspection purposee. —� Sign6turEKof Permittee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE /