HomeMy Public PortalAbout9846 LONGDEN AVE_Sewer__ I
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 1303210005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: ISEWER / SEPTIC: SEWER I BUILDING ADDRESS: I
ON FILE 11EXIST OCC GRP: I 9846 LONGDEN AV I
BLDGS. NOW ON LOT: I TEMP CA 917801424 I
(ASSESSOR INFORMATION NUMBER: (CONNECTION TYPE: I NEAREST CROSS STREET: I
15385-022-003 (ORIGINATION: I THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY CAI
I 11LENGTH ML TO PL: STATION: DEPTH: I
ITENANT: IMANHOLE REFERENCE: UPPER/LOWER: ISSUED ON: PROCESSED BY: [
I I 103/2i/13 SR 1
(COUNTY IMPROVEMENT NUMBER: I
(OWNER: TEL. NO: IPLAN CHECK NUMBER: I FINA14 DATE FINAL BY: CODE:
IJAGIELSKI HAROLD L;SUNG H (626) 286-6048- (JOB NUMBER: I�
19846 LONGDEN AV 'ITRUNK PERMIT NUMBER: I
ITEMP 917801424 IROAD PERMIT NUMBER: 1 C PTION
I IAFFADAVIT: NO ISEWER SPO REPAIR I
IWAIVER: NO I I
(APPLICANT: TEL. NO: 1EASEMENT: NO I I
ISNEDDON, JOSHUA (626) 258-9284- 1 I I
1475 E ARROW HWY 1RECORD INSTRUMENT NBR: RECORD DATE: ISPECIAL CONDITIONS: I
IAZUSA CA 91702 1HIGHWAY/STREET WIDENING: 1
ISTATE ENCROACHMENT PERMIT NUMBER: [
ICONTRACTOR: TEL. NO: I FEES PAID [APPROVALS DATE INSPECTOR SIGNATURE
[RESCUE ROOTER (626) 858-9284- ' 1
1475 E ARROW HWY LIC. NO IFEE DESCRIPTION: QUANTITY: UOM: AMOUNT:INEW HOUSE SEWER I I
IAZUSA CA 91702 765155 * I
I 101 PERMIT ISSUANCE FEE 27.80 1CONNE�:T ADDITIONAL I
I 115 ALT/REP HOUSE SEWER 1.00 EAC 30.50 JBUILdING OR WORK I I I
[ARCHITECT OR ENGINEER: TEL. NO: I TOTAL FEES 58.30 1 I I I
I - i ISEPTI.0 TANK, SEEPAGE PITI I I
[ LIC. NO: I JAND/OR DRAIN FIELD I I I
IDRYWELL _ 1
I i I I I I
1 SEWER MAP BOOK: PAGE: I (ALTER, REPAIR, SEWER OR I I I
ISEWAGE DISPOSAL SYSTEM
[ I [DISCONNECT PLUG AND I I
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I i [ABANDON HOUSE SEWER I I I
I I IBACKFILL SEPTIC TANKS
ISEEP. PIT _ CESSPOOL
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IGRAYWATER SYSTEM I I
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I P* ADDITIONAL DATA ON FILE
i
IREPORT ID: DPR266 ROUTE TO BS0508 I I I I
I I I I I 1
WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate of consent to self
It in7ye, or a certificate of Workers'Compensation Insurance, or %'eA6n2D
a certified copy thereof (Sec. 3800, Lab C.) gEON(REV.8/81)
PoAPPLICATION FOR PERMIT
li rK3o. ,Company bJs
❑ 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' BUILDINGi
COMPENSATION INSURANCE ADCRESSr �{ t STATION DEPTH
(This section need not be completed if the work involved by the LOCALITY ' CE' c4 r MANHOLE REFERENCE /'�
perm .it is for one hundred dollars ($1001 or less.) +` T7 r �(/ owea
NEAREST TYPE OF CO ON LENGTH FROM �r
I certify that in the performance of the work for which this CROSS ST. Y. CCURS M.L,TO P.L.
permit is issued, 1 shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. / /�f •pyo P.C.NO.
I p OWNER �t G(..��f CO IMP.NC. fes!' JOB NO.
MAIL r-" TRUNK.PERMIT NO. ROAD PERMIT NO.
Date Applicant ADDRESS
NOTICE TO APPLICANT: If, after making this Certificate of CIT ✓J 4 AFFIDAVIT JJAIVER EASEMENT RECORD.INSTR NO DATE
��� TEL.NO.
e�
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 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 Busi- BUILDINGS CHARGES
ness and Professions Code, and my license is in full force and
CONTRACTOR �,�
effect.
CONNECTION CHARGE FEE
d
License Number Lic.Class ADDRESS �J REIMBURSEMENT FEE O
COntl"aCtOr Date _t
4(1A_&,733
�M r DISTRICT NO,, GROUP MAP OCESSED BY U
CITY TEL.NO. � ( .J "' "" BK PG - Z
❑ I am exempt under Sec. of the L.A.Co. STATE LTC. _ -! t y O
p LICENSE NO. CLASS )t `! L , �.,.,..
Plumbing Code and/or Sec. of the NO. DESCRIPTION OF W RK FEE IAL u V
HOUSE SEWER CONNECTING TO DATE f V (DATION lo.
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
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFI hereby affirm that I am exempt from the Contractor's License EXTN.CCESSPEOOLEPAGDRYWDRAMAN OLE 010. 10
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code): SEWER OR DISPOSAL SYSTEM
r,-�
❑ I, as owner of the property,or my employees with wages as "'4�'£r' c;';
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 $ 10
1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE na €I-` ' 7 - 50
licensed Contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO - NECK 27.51
Business and Professions Code). CONNECT THE ABOVE DESCRIBE°°EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY !7 c}C ® :h E
I hereby affirm that there is a construction lending agency SIGNED THIS r D Y 1 198
for the performance of the work for which this permit is OWNER
OWNERS A AGENT
issued (Sec. 3097, Civ. C.). r #- 9 t t_?:• "o
ADDRESS Ltt l;Ii —I I„I„j .: i...... E.i.
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,
and41he
hereby authorize representatives of this County to enter
abov -menti d property for ' spection purposes.
ti
Signature of Pe itie� Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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