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HomeMy Public PortalAbout6218 LOMA AVE_Sewer__ DF.PARTbMNT OF COUNTY ENGLNEER SEWER—SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER BUILDING ADDRESS ADDRESS � �VN -C;k FOR APPLICANT TO FILL IN LOCALITY BUILDINGy p.I� NEAREST Q� ADDRESS �! Uy _ CROSS ST. �� LOCALITY + DISTRICT NO. SERIAL NO. PERMIT NO. NEAREST `+ S A _ -'2..'` I� S CROSS ST: ��^^ ,, ! RECEIVED BY Ready for Inspection DATEISSUED OWNER L9 MAIL r r•,� ' �� s ,� USE ZONE OCCUPANCY BK MAP PG ADDRESS CITY C TEL.NO. (�"�a / _ �� I • CONTRACTOR M. C. Notfl°naham Co: Of Tempfe M�i CO.IMP.NO. � zg CA S qc_ ADDRESS 5933 N. CLOVERLY AVE. JOB.NO. --� CITY P6Ffi CALIF. U::.:., n TRUNK PERMIT NO. �f� 917'41 �7�/� STATE REGISTRATION N0. �^ [ COUNTY ROAD PERMIT NO. LEGAL L ® DESCRIPTION LOT NO. I J TO/ � STATE ENCROACHMENT PERMIT NO. BLOCK TRACT �Qv �r items. INDUSTRIAL I WASTE APPROVAL NO.OFBLDG SIZE OF LOT 4o NOW ON LOTS CHARGES USE OF BUILDINGS 10 CONNEC CHARGE FEE NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT F _ PUBLIC SEWER Q $ 3.50 4 RECEIPT NO. Af�E IBY HOUSE SEWER CONNECTING TO , PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR �rEXCEPTION RECORDED WORK TO HOUSE SEWER 1.00 NO. ALTER OR REPAIR EXISTING I DATE 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 I MANHOLE REFERENCE IPS • ��P� LDS TYPE ��ECTION _ LENGTH FROM 1 OWNERS PERMIT $ I 1 00' '= CURB) M.L.TO P.L. 3Q AUTHORIZATION ( TOTAL FEE 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'SSIGNATURE DATE n DWELLING TO THE PUBLIC SEWER ^ _ y ._.__DAY OF.. Yt!! _� NEW HOUSE SEWER SIGNED THIS....__ ____19>. OWNER OR CONNECT ADDITIONAL OWNERS AGENT•_...... BUILDING OR WORK - 13<_✓ SEPTIC TANK,SEEP.PIT(S) ADDRESS_L-}.I.5L....__ ...L_. -..__....._.........._... AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL E] 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. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT ABANDON HOPLUG PLUGAND AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ER OF THE AB _ EESQ )V LMPERTY. BACKFILL SEPTIC TANKS . �. I�j U ^� "" SEEP.PIT(S) CESSPOOLS❑ SIGNATURE — OF PERMITTEE �L)� Z� 76AG42A 663 7/53 , WORKERS'COMPENSATION DECLARATION I hereby affCompensation Insurance, or'. that I have a certificate of consent 'to self ' insure-ora Certificate of Workers'Compen ' 76A6429+ a certified copy thereof (Sec. 3800, Lab C.) CE 808(REV.B/ell APPLICATION FOR PERMIT . Policy No. Company ©$ ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL ❑ 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' FIDING &d) / STATION DEPTH COMPENSATION INSURANCE V. (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOWER NEAI certify that in the performance Of the Work for which fhi5 TYPE OF CONNECTION LENGTH FROM V. CURB P.L. M.L.TO P.L. A permit is issued, I shall not employ any person in any manner ! so as to become subject to the Workers'Compensation Laws. Lf � P.C.NO. 0 OWNER CO.IMP.NO. JOB NO. � ADDRESS N,MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ,�qq AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE 0 NOTICE TO APPLICANT: If, after making this Certificate of CITY TEL.No. ✓�3 7�� L` Exemption, you should become subject to the WorkersLEGAL j� ,or+ Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO.ill, HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK 621 TRACT {J STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. m SIZE OF LOT40 A NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF p ^ 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGSCHARGES 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. CITY TEL.NO. DISTRICT NO. GROUP MAP PROCESSED BY BK PG ❑ I am exempt under Sec. of the L.A.Co. STATELIC. SE No. / SS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO DATE VALIDATION B. 8 P. Code for.the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Dote HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR I OWNER-BUILDER DECLARATION I WORK TO HOUSE SEWER l OVERFLOW SEEPAGE PIT,DRAINFIELD {Iltl I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE `a, /7 E,7 A fessionS Code): SEWER OR DISPOSAL SYSTEM 1 El 1,as owner of the property,or my employees with wages as ". c;o 0 0 0 their sole compensation, will do the work and the structure o 0 2 1, 5 is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ El 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE r� 2 "G c licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO G 2 0'7=8 4 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY , 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 issued (Sec. 3097, Civ. C.). OWNERS A AGENT ADDRESS ender's Name rider's Address certify that I have read this application and state that the ove information is Correct. I agree to comply with all County dinances and State laws regulating Plumbing and Sewers, d hereby authorize representatives of this County to enter on t e above-mentioned property for inspection purposes. nature of Permittee U Date SEE REVERSE FOR EXPLANATORY LANGUAGE