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Home My Public Portal About9440 LEMON AVE_Sewer__ 7a E-66 APPLICATION FOR PERMIT 7 9&6.869 3•SD APPLICATION P'Y - 1 DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Loa Angeles BUILDING Q C Q N WM.J. FOX. COUNTY ENGINEER ADDRESS L CASSATT D.GRIFFIN, SUP'T OF BUILDING LOCALITY NEAREST FOR PLICANT TO FILL IN CROSS ST. V LEGAL b� DESCRIPTION LOT NO'�r�Y ^ '�+ n IOWNER 1A GK � �t V�,( BLOCK TRACT SA IV T�4- /�/,,_ MAIL �T �A/I•p 'ADDRESS ' NO. OF BLDGS. - SIZE OF LOT N ON 0 ICITY TEL. NO. USE OF ,,,J BUILDINGS C C DISTRICT NO. GROUP MAP Z7IK PG' CONTRACTOR C O , ADDRESS 5��,,(> V� He y � l v 4, CONNECTION DATA CITY /-'� .ZJ•-Z� TEL. NO.Lo+n CJ STATION 0 , '9 DEPTH ATE MANHOLE REFERENCE UP REGISTRATION NO. ❑ COUNTY E NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTI�1�'� LENGTH FROM HOUSE SEWER CONNECTING TO Q $ 3.50 Y. CURB / P.L. / M.L. TO P L. PUBLIC SEWER HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 _ 'CONNECT ADDITIONAL BLDG. OC.R CO. IMP. NO./_! —\ JOB Nb 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 2.00 INDUSTRIAL - 'CESSPOOL-DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CHARGES pER1�TT CONNECTION CHARGE FEE OWNER'S S I 00 AUTHORIZATION ITOTAL FEE REIMBURSEMENT FEE HAVE ITRACTOR DATE CONNECT CONTRACTED ITH THE EXISTING DWELLING CON- APPROVALS DATE INSPECTOR'S S IGNATURE TO THE PUBLIC SEWER SIGNED THIS DAY OF 19_ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR'WORK SEPTIC TANK, SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[3DRYWELL C)AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY - WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR _ PLUMBING AND SEWERS. SEWAGE-DISPOSAL SYSTEM - 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER - DESCRIBED RESIDENTIAL PROPE BACKFILL SEPTIC TANKS❑ /J //� SEEP. PIT(S) 0 CESSPOOLS SIGNATURE ' - OF PERMITTEE WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR iol 1-- S10 a -4.50 - 0 WORKERS' COMPENSATION DECLARATION 200051 DPW 6/89 I hereby affirm that I have a certificate of consent to self U Insure, or a certificate of Workers' Compensation Insurance, or 76A642D a certified copy thereof (Sec 3800, Lab C , APPLICATION FOR PERMIT Policy No Company , SEWER - SEWAGE DISPOSAL Certified copy is hereby furnished r El ❑ Certified copy is filed with the county building Inspection COUNTY OF LOS ANGELES BUILQONG,�ND•SA,FFTY department }` Date Applicant FOR APPLICANT TO'FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BDILDING ,,,ryyy COMPENSATION INSURANCE ADDRESShtt STATION 1774-1157" 7I �/ DEPTH (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 .��. M NEAREST TYPE OF CONNECTION LENGTH FROM I certify that In the performance of th work for which this CROSSST Y CURB r M L TO P L permit Is Issued, 1 shall not employ a person in any manner LEGAL PC NO so as to beco a subject to the Worke ompensation Laws DESCRIPTION LOT NO CO IMP NO JOB NO BLOCK TRACT - TRUNK PERMIT NO ROAD PERMIT NO r Date Applicant NOTICE TO A PLICANT If, after mak n this Certificate Of ASSESSOR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE MAP BOOK PAGE PARCEL Exemption, you should become subject to the Workers' NO-OF BLDGS Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NOW ON LOT HWY OR ST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked BUILDINGS STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER ��r7 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL ADDRESS CHARGES ness and Professions Code, and my'license is In full force and effect CIT C4 CONNECTION CHARGE FEE EL NO License Number r Lic Class 6- REIMBURSEMENT FEE CONTRACTOR Contractor Date DISTRICT NO GROUP MAP PROCESSED BY • ADDRESS �p CJ C// BK PG ❑ I am exempt under Sec of the L A Co d • CITY TEL NO -? - ✓ //� v /� O Plumbing Code and/or Sec of the SCENSE NO ComCLASS `� DATE VALIDATION Z B 8 P. Code for the following reason NO DESCRIPTION OF WORK FEE - Q HOUSE SEWER CONNECTING TO FINAL (•- Date PUBLIC SEWER BY u W SEPTIC TANK SEEPAGEPIT OR - d Signature MM PITS AND OR DRAINFIELD N OWNER-BU ECLARATION HOU 1E Sewell CONNECTING TOpoll Z RIVATE DISPOSAL SYSTEM I hereby affirm that I am ex pt from the Contractor's License CONNECT ADDITIONAL BLDG OR Law for the following reason (Secton 7031 5, Bulsness and Pro- WORK TO HOUSE SEWER 1°1 OVERFLOW SEEPAGE PIT,DRAINFIELDA ACCT. fessions Code) EXTN CESSPOOL DRYWELL MANHOLE ❑ j,as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE their sole compensation, well do the work and the structure SEWER OR DISPOSAL SYSTEM 330 53.70 is not Intended or offered for sale (Section 7044, Business ITEMS and Professions Code) ❑ I, as owner of the property, am exclusively contracting with OWNERS Permit $ (� TOTAL53,_ 70 licensed contractors to construct the project (Section 7044, Business and Professions Code) AUTHORIZATION I TOTAL FEE 3. D CHECK 53.70 CONSTRUCTION LENDING AGENCY I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO '}-!L I hereby affirm that there IS a construction lending agency CONNECT THE'ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER Poo. C • G .013 for the performance of the work for which this permit is Issued (Sec 3097, Civ C ) SIGNED THIS DAY OF )9ER OR0000-0001 - ?/ ,9 Lender's Name OWNERS AGENT jjj��ji� { {�y { Lender's Address ADDRESS 2,11 1 AM10oil I 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 hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE