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HomeMy Public PortalAbout9624-9626 LONGDEN AVE_Sewer__ 16A 642D -GE808-10-71 APPLICATION FOR PERMIT ` COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS 5T DESCRIPTION LOT NO. of tl�JTA 1 1,1 OWNER - - MAIL BLOCK TRACT ADDRESS NO. OF BLDGS. - SIZE OF LOT NOW ON T i CITYC, ;.,y,� TEL. NO. USE OF DISTRICT N0. GROUP MAP PROCESSED 8Y BUILDINGS 9 - q 4 SK pa CONTRACTOR Fv �^- ADDRESS CONNECTION DATA r— CITY TEL. NO. STATION DEPTH G STATE LIC MANHOLE REFERENCE LICENSE NO, CLASS ♦ LOWER NO. .DESCRIPTION OF WORK FEETYPE OF CONNECTIO LENGTH FRO HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L-TO P.L. PUBLIC SEWER @ $7.00 �+y SEPTIC SEAGE PIMPNO TANK. EPT OR �„J` P.C.ND. PITS AND/OR DRAINFIELD @ $10.00 CO.. . . JOB'N O. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 0. PRIVATE DISPOSAL SYSTEM _@ $3.00 O CONNECT ADDITIONAL D BLG.OR AFFIDAVIT I wAIVII IASIMINI RECORD.INSTR.NO. DATE V WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD Oz EXTN._CESSPOOL.D Y•W4i=' . @ $5.00 Q ALTER, AY� OU HWY.OR ST.WIDENING SEWE OR D ISPOSA S�V�SM__ @ S3.00 STATE ENCROACHMENT u __- —t- -- -- __ — W MANHOLE 0 $7.00 PERMIT NO. 0. ------ - INDUSTRIAL N WASTE APPROVAL OWNER•s PERMIT CHARGES 3 CHARGES AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT - CONNECT ADDITIONAL BUILDING OR WORK ADDRESS__ SEPTIC TANK,SEEP,PITS) I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 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 OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AMTHELEGAL OWb4'ER OF. AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED 'R5kfOt`NTIAL' PROPERTY. 1 ABANDON HOUSESEWER� SIGNATV RE BACKFILL TIG TAN ❑ OF PERMTTTE .. .__. .�.. __--- SEEP,PiT(S) ❑ CESSPOOLS ❑ VALIDATION K. M.D. `ASK ,WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800 Lab C) CE 808(REV.B/Bi) APPLICATION FOR PERMIT Policy No `� _fJCompany �, +r#� f�et /*bg-+`. � C ©a ❑ 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 P 1 j Applicant_ _: ^E FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' FPTI.N G wq�� d,)1^4,? STATION DEPTH COMPENSATION INSURANCE SS • �7 L lY 4# 4! Y (This section need not be completed if the work involved by the '"� � MANHOLE REFERENCE LOWERpermit is for one hundred dollars ($100)or less.) ST = ¢ {I certif that in the erformance of the work for which this T rr^^� "`,. TYPE OF CONNECTION LENGTH FROM y p 5T l sem'/y �;,,G- �.Z � - e§` ,.� Y. CURB P.L. M.L.TOP Lpermit is issued, 1 shall not employ any person in any mannee yso as to become subject to the Workers'Compensation Laws. R Ji< n�'(ty� ,, , � CO.IMP NO. JOB NO. MAILDateApplicant_ ss /7C� .� ♦'J ib7 /� TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makin this Certificate ofc :� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE g rJ� ;j TEL NExemption, you should become subject to the Workers' AL !�Compensation provisions Of the Labor code, you must forthwith PTION LOT NO. HWV.OR 5T.WIDENING comply with such provisions or this permit shall be deemed revoked. TRACTSTATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION No.of BLDGs. PERMIT No. F LOT NOW ON LOT I hereby affirm that 1 am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR ®� p y`r /'t-�14— CONNECTION CHARGE FEE a License Number Lic..Class, ADDRESS • i (,,$,�.7�' a .' d� p�. :,r`� ,i 49,,,), REIMBURSEMENT FEE DISTRICT NO. GROUP MAP PROCESSED BY V Contractor Date CITY �. �J� TEL.N .'I' ' J�"'/ , 1' `,. r, I .-7 BK PG Z STATE yy, AIC. �'"t�' �" Y'= O El lam exempt under Sec, of the L.A.CO. LICENSE NO. Gs N CLASS NO. DESCRIPTION OF WORK FEE W Plumbing Code and/or Sec. of the FINAL r HOUSE SEWER CONNECTING TO q 7 ��11 DATE ,/�/ VALID,4TION o- B. & P. Code for the following reason PUBLIC SEWER { f -���Jl - Z PITSA TANK,SEEPAGE PIT OR FIfJ PITS AND/OR DRAINFIELO Date BY 5 2 1, A HOUSE SEWER CONNECTING TO ./ !tI =�-� PRIVATE DISPOSAL SYSTEM T m e 0 • Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD 1 hereby affirm that I am exempt from the Contractor's License ExTN..CESSPOOL,DRYWELL,MANHOLE Low for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE 9 a y fessions Code): SEWER OR DISPOSAL SYSTEM J y I E -86- 6- ❑ I,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 and Professions Code). OWNERS Permit $ JJ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE '? (((�� licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 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 OAGENT issued (Sec. 3097, Civ. C.). ADDRESS ' Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. 1 agree to comply with all County ordinances and State laws regulating Plumbing-and Sewers, and hereby authorize representatives of this County to enter upon t e above-mentione property for inspection purposes Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE ,WaRKERS'COMPENSATION DECLARATION fhereby wffirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76Aea2D a certified copy thereof (Sec. 3800, Lab C.) CEBOB(REV 881) APPLICATION FOR PERMIT Policy No. .t,I'—3;_-f ompany A 7/1 21 y-?,4CfVP;) 'G�, (e�s ❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departmgnt, Date &f °a� Applicant_ 1"_, .._#!•' f�`'- FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' fNIARESTLE ING srnnoN DEPTH COMPENSATION INSURANCE RESS ` v' "� (This section need riot be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) ALITY ` /�? L �'i [ LOWER I certify that in the performance of the work for which this 5T. TYPE OF CONNECTION ,,,,vv�� LENGTH FROM ?✓ L'•` .: 'C^- i � —5 a Y. CURB P.I. M.L,TO P.L. permit is issued, I shall not employ any person in any manner _ so as to become subject to the Workers' Compensation Laws. /r P.C.NO. I P OWNER �/ems ���,-� �(„Y C-.���,� �y� CO.IMP.NO. JOB NO. MA Date Applicant ADDILRESS �J d r : ;. (,,D-L0/4) 40 TRUNK PERMIT NO. ROAD PERMIT NO NOTICE TO APPLICANT: If, after making this Certificate of CITY fkl, �i7 TEL N L. }t AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE ' s Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed L revoked. BLOCK TRACT Li43 STATE ENCROACHMENT NO,OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter UE OF 9 (commencing with Section 7000) of Division 3 of the Susi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR ltaya �,J.' j ,fsG (� /j1fl CONNECTION CHARGE FEE a License Number Lic.Class_ ) "� 2 ADDRESS�„f„1 -� tIy, `�}�f� t'/C.:.� „� t�L � REIMBURSEMENT FEE Q -y DISTRICT NO. GROUP MAP PROCESSED BY Contractor_ Date CITY f 1 � t D TEL.NO.4 1 p — 1 7 / lJs,]� Z ❑ I am exempt under Sec. of the L.A.Co. STATE f y�' ilC. � / 15 BK Pr., Q P LICENSE NO/ O CLASS 1 Plumbing Code and/or Sec. of the NO. DESCRIPTION Of WORK FEE FINAL W HOUSE SEWER CONNECTING TO '--- DATE VALID ION LU B. & P. Code for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FiNA Z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Z, 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 Low for the following reason (Sectors 7031.5, BuiSness and Pro- ALTER,REPAIR OR ABANDON HOUSE t3 fessions Code): SEWER OR DISPOSAL SYSTEM ❑ I,as owner of the property,or my employees with wages as j • • • • 0 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business 2 J 0 .and Professions Code). OWNER'S Permit $ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ` t ®,s • 2 7-5 0 E licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. r n8 1 -86 y,� CONSTRUCTION LENDING AGENCY poll. 0 1 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 issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address 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 propert for inspection purposes. s � , Signature of Permittee Dater SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION i^hefeby affirm that I have a certificate of consent to self insure, oro certificate of Workers' Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, Lab C.) z r CE 808(REV.8/81) APPLICATION FOR PERMIT Policy No#r Corn pony. f'�v"Y' J _. �'h . L_�� Os ❑ 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. �.. Dote�/ Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �x STATION DEPTH COMPENSATION INSURANCE ADDREssA /1 6 -N t� (This section need not be completed if the work involved by the f? _ MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100) or less.) LOC �/ �. - i Y LOWER I certify 11141 in the performance Of the Work for which this NEAREST q _ r TYPE OF CONNECTION LENGTH FROM Y P CROSS ST_ y �z' �.i F ,IL�> Y. CURB P.L. M.L.TO P.[, permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. OWNER rl)Je,- } � q�^y�d.� � G CO.IMP.NO. JOB NO. MAIL Date Applicant ADDRESS 9 � � > fJ / t ,I dr TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE TO APPLICANT: If, after making this Certificate of CITY t)&1�.1 { TEL N AFFIDAVIT VdAIVER EASEMENT RECORD.INSTR NO. DATE Exemption, you should become subject to the Workers' p9r Compensation provisions of the Labor code, you must forthwith LEGAL fr P P Y DESCRIPTION LOT NO. WWY OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT C`� STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO,OF BLDGS PERMIT NO. 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 CHARGES ness and Professions Code, and my license is in full force and CONNECTION CHARGE FEE effect. CONTRACTOR *' �' �x9 t (1 License Number LiC.Class_ ADDRESS2. •67ys >T� � .�r -./, REIMBURSEMENT FEE O. Contractor Date ,[' 121 >' a' 'DISTRICT NO. GROUP MAP ROCESSED 8Y CITY �s /',_ TEL.N z7� f' / �>J� f� 8K PC Y Z STATEj ,yyy,,!,r LIC. ,`" jjI ',d' ✓ � O ❑ I am exempt under Sec. Of the L.A.Co. LICENSE NO. , z,' t 1(G l CLASS ""LL r NO. DESCRIPTION OF WORK FEE (,� Plumbing Code and/or Sec. of the DATE VALI TION LU HOUSE SEWER CONNECTING TO `p✓j DA7E PUBLIC SEWER B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR '/ Z PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY n F� PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER —45 2 1,9 N OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.CESSPOOL,DRYWELL,MANHOLE { /1 Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE t ® a • J fessions Code): SEWER OR DISPOSAL SYSTEM 7,50 ❑ I,as owner of the property,or my employees with wages as ± ® t- their sole compensation, will do the work and the Structure � X is not intended or offered for sale (Section 7044, Business s 2' f' 5 0 t> and Professions Code). OWNERS Permit g 1 1 �8 I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 1213- licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A. CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 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 OR issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address 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 Datd SEE REVERSE FOR EXPLANATORY LANGUAGE WCIRKERS'COMPENSATION DECLARATION «heveby '5ffirm that I have a certificate of consent to self i..7sure, or Q certificate of Workers'Compensation Insurance, or 76A6420 a certified copy thereof(Sec. 3800, Lab C.> ,� CE 80B(REV.B,B„ APPLICATION FOR PERMIT Policy No r$,Company>'+'`R_' Ji�� JT C rse s- rs ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departm Date 41 (1 Applicant a , 'y'' -'r. FOR APPLICANT TO FILL IN CONNECTION DATA 'CE TIFICATE OF EXEMPTION FROM WORKERS' BuaDwG ± ,y COMPENSATION INSURANCE ADDRESS ' �vu �ll = I STATION 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 ! LOWER 1 certifythat in the performance of the work for which fht5 NEAREST _ t TYPE OF CONNECTION LENGTH FROM P CROSS ST. � C ( ! Y. CURB P.L. M.L TO P.I. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Lows: ° +a�y�`�^ �'.7 P.C.NO. OWNER g� L�=:�- b` ¢i j>,�• CO.IMP_NO. J08 NO. Date Applicant ADDRESS ✓OCT ..J v � A3 W v�7 TRUNK PERMIT NO ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate Oh AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE hff CTfY ''l'"`L.�,r�J�L+"�s�" TEL.N 2 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT 3 w STATE ENCROACHMENT NO,OF BLDGS. PERMIT NO. LICENSED CONTRACTORS DECLARATION 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 BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and _ ,7 effect, CONTRACTOR f" �<., ,✓ s+ ._ ��"�j� �/' J�' iLt CONNECTION CHARGE FEE >, License Number Lic.Class_ ADDRESS 111 j'1T O c REIMBURSEMENT FEE . Contractor Date "y DISTRICT NO. GROUP MAP PROCESSED BY CITY `..-- f9" /�-.i/ TEL.N 2�./ "] '� rJ BK PG J / Z ❑ I am exempt under Sec. of the L.A.Co. STATE No. �,: " class NO Plumbing Code and/or Sec. of the . DESCRIPTION OF WORK FEE rd FINAL 01VALID ION O,.W HOUSE SEWER CONNECTING TO "1 -'�'. GATE PUBLIC SEWER J _ f,�I B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD F1 Date Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM �` Signature CONNECT ADDITIONAL BLDG-OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License EEXTN.,CESSPOOL, ss OOL,DRYWELL, AAN OLE Law for the following reason (Secton 7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 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 and Professions Code). OWNERS Permit $ S' _5 L 2 0 A 1,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE • • • ® € G licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBUC SEWER. n • r G l+7 5 u V CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED I E DTHIS DAY OF 19_ 00 • • • for the performance of the work for which this permit is O2 7, 5' 0 C issued (Sec. 3097, Civ. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address 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-mentionedI property for inspection pur oses. gnature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WOR S'COMPENSATION DECLARATION I hereby that I have a certificate of consent to self iulsuri, or aR; rtificate of Workers'Compensation Insurance, or 76A642D a.ertified py)her f Sec. 3800, Lab C.) CE 808(REV.8!87) APPLICATION FOR PERMIT Policy No. ampany l,¢aJ f%`` t �_t OOs ❑ C . Ifed copy is hereby furnished. SEWER - SEWAGE DISPOSAL ertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY derp�u/rtm Q �///Date Y f� r � Applicant L�''` FADD OR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' ING % � y COMPENSATION INSURANCE ESS `/ae� j STATION DEPTH (This section need not be completed if the work involved by theIICj a~.}� MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LITY rP is e LOWER I certifythat in the performance of the Work for which ihlS EST ' TYPE OF CONNECTION LENGTH FROM P S ST. / -f T,� L—V " Y CURB P L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner _ �I so as to become subject to the Workers'Compensation Laws. ER Ole'` 14"bt: l- J�Iw`r� 41 11et CO.IMP.NO. JOB NO. ' ! TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ESS tt f', �� �! /(� NOTICE TO APPLICANT: If, after making this Certificate Of r ! AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE, Exemption, you should become subject to the Workers' �� TfL N ' � - Compensation provisions of the Labor code, you must forthwith GALp p Y RIPTION LOT NO. HWV_OR ST.WIDENING comply withsuch provisions or this permit shall be deemedrevoked. K TRACT ` STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO.OF BLDGS. PERMIT NO. OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter F9 (commencing with Section 7000) of Division 3 of the Busi- INGS CHARGES ness and Professions Code, and my license is in full force and r effect. CONTRACTOR y�..E` P�'!\ /gjofif'tG�' `� °'1P � ' CONNECTION CHARGE FEE License Number LiC.Class ADDRESS . ' REIMBURSEMENT FEE Q DISTRICT NO. GROUP MAP PROCESSED BY CITYTEL.N 's "� * " Contractor Date ! BK PG Z ❑ I am exempt under Sec. of the L.A.Co. STATE No '' CLASS '?` � O ✓^' 0 V Plumbing Code and/or Sec. of The NO. DESCRIPTION OF WORK FEE Fwnl / HOUSE SEWER CONNECTING TO DATE VALID , ION IW ILB. $ P. Cade for the following reason PUBLIC SEWER SEPTIC TANK,SEEPAGE PIT OR FIN Z PITS AND,OR DRAINFIELD Date HOUSE SEWER CONNECTING TO f PRIVATE DISPOSAL SYSTEM n Signature CONNECT ADDITIONAL BLDG OR 2 Z q 1 A OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER SEEPAGE 1 hereby affirm that I am exempt from the Contractor's License EUXTNFLOCES POOL,DRYWEDLRLAMANHINFIELOLE , ® * 0 Law for the following reason (Sector)7031.5, BUisness and Pro- ALTER,REPAIR OR ABANDON HOUSE , fessions Code): SEWER OR DISPOSAL SYSTEM a 0 2 7,5 0 ❑ 1,as owner of the property,or my employees with wages as g e nZ their sole compensation, will do the work and the structure �' 'c is not intended or offered for sale (Section 7044, Business 0 ._ J[ and Professions Code). OWNER'S Permit $ 7 l' I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE `T r licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO 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 OR Issued (Sec. 3097, CIV. C.). OWNERS AGENT ADDRESS Lender's Name Lender's Address 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 pFoperty for inspection p rposes. �• r�� i�.��' -'�.,C! 1E, � � Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE