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Home My Public Portal About9574-9576 LOWER AZUSA RD_Sewer__ r V � CES083 Bx APPLICATION FOR PERMIT TeAesaD COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS d y�, COLEMAN W JENKINS SUP T OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FB.L IN CROSS BT L GAL DESCRIPTION LOT NO OWNER liew MAIL BLOCK TRACT ADDRESS NO OF BLDGb SIZE OF LOT NOW ON LOT CITY Vol jft44L NO USE OF BUILDINGS BK DISTRICT NO GROUP MPO AP PROCESSED BY r CONTRACTOR ADDRESS l1_4,eV' CO CION DATA CITY TEL NO STATION �g DEPTH UPPER STATE ` LIC MANHOLE REFERENCE // Y LICENSE NO OLA86 d? V I NO DES I OF WORK FEE TYPE OF CONNECTION LENGTH FROM MOUBE SEWER CONNECTING TO Y CURB P L ML TO P L d PUBLIC BEW ER 1jD 00 PC NO O SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO V PITS AND/OR DRAINFIELD SIO 00 HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM $300 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EAEIYEMT RECORD INSTR NO DATE r WORK TO HOUSE SEWER $300 `YJJ OVERFLOW SEEPAGE PITDRAINFIELDIL EXTN CESSPOOL DRYWELL MANHOLE 41 $500 y AI�BRIERl�MM/FOR ABANDON HOUSE V Y HWY OR BT WIDENING Z SEWER Qa Obb SYSTEM $300 STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGEE OWNERS PERMIT s 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING OWELLING "R* TO THE PUBLIC SEWER RO•L'� S DATE INSPECTOR 8 SIGNATURE SIGNED THIS-DAY OF 19_ OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK ADDRESS 6HPTIC TANK SEEP PIT(B) 1 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 ❑ 1 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 le CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN TH BONE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE FILL SEPTIC TANKS ❑ OF PERMf7TEE BEEP PIT(S) ❑ CESSPOOLS VALIDATION JACK ALLEN CK M O CASH SUPERVISING MECHANICAL ENGINEER LAP,2 4 0 7 ,- OP,124 1 0 0 5.00- q t i WORKERS COMPENSATION DECLARATION CE 808 2 80) APPLICATION FOR PERMIT I hereby aArm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL idsure or st certificate of Workers Compensation Insurance or a certified c e e f(Sec 3800 Lab COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company_T r/ Certified copy u hereby furnished FOR APPLICANT TO FILL IN Il /CONNECTION DATA BUILDING 57 L/ p� STATION �/ -?-?, d DEPTH ADDRESS / 7 a Certified copy B filed with the county b�iilding inspection_ UPPER /^�J f LOCALITY L o w e v- Z t47— RDS I, ANHOLE REFERENCE tam Date d�r Applicant &b / ` �� NEARESTTYPfi OF CONNECTION L6NG X FROM CERTIFICATE OF EXEMPTION FROM WORKERS CROSS ST J e K ` C, u Y CURB P L M L TO P L COMPENSATION INSURANCE OWNER kcfj d V CO IMP NO J c No �.I/T JOB NO AIL (This section need not be completed /f the work Involved ADDRESS B e IDv, O D{.r D � RUNK PERMIT NO ROAD PERMIT NO >_by the permit Is for one hundred dollars ($100) or less) a ^ - AFFIDAVIT WAIVER BASEMENT RECORD INSTR NO DATE a CITY giv (/eV TEL No S ilo 6 V 1 certify that in the performance of the work for which this LEGAL permit is issued I shall not employ any person in any manner DESCRIPTION LOT NO Y HWY OR ST WIDENING cc so as to become subject to the Workers Compensation Laws O BLOCK TRACT STATE PERMIT NENCROACHMENT V Date Applicant OF BLOGS W NOTICE TO APPLICANT If after making this Certificate ofICITY_Tl�oc size oP Lor Now on LOT CL USE OF to Exemption you should become subject to the'WorkersBuiLDilvasi criaRGfia Z Compensation provisions of the Labor Code you must forth [^ with comply with Such provisions or this permit shall be CONTRACTOR ` v� CONNECTION CHARGE FEE deemed revokedMBURBEMENT F6E LICENSED CONTRACTORS DECLARATION ADDRESS I✓I hereby affirm that I am licensed under provisions of ChapterL[luv� rEL o3 GIp DISTRICTNO GROUP MAP PROCESSED BY 9 (commencing with Section 7000)of Division 3 of the Busi " / /HUK PG O ` ness and Professions Code and my license is in full force and LICENSE S D�00 TATE cLnsa C b �� 2 effect NO DESCRIPTION OF WORK FEE 1,01 HOUSE SEWER CONNECTING TO FINAL VALIDATION License Number A5740 60 Ltc Class C -36 PUBLIC SEWER DATE SEPTIC TANK SEEFAGH PIT OR (Contractor_,90v 11 A0 PITS AND/OR GRAINFIELD FINAL � Date HOUSE SEWER❑ CONNECTINGTO BY PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER /6 _ acting in my professional capacity (Section 7051 Bus OVERFLOW SEEPAGE PIT DRAINFIHLD �tJ mess and Professions Code) EXTH CESSPOOL DRYWHLL MANHOLE ALTER REPAIR OR ABANDON HOUSE SHWHR OR DISPOSAL SYSTEM Lic or Reg No Date HOME OWNER BUILDER DECLARATION y, f 'ko' 4 ' OWNER'S Permit s y 42-i..-s.� I hereby affirm that I am exempt from the Contractors License Law for the following reason (Section 7031 5 Busi AUTHORIZATION TOTAL FEE � �2�.C.4 � ¢ ness and Professions Code) n 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON A �� K qJ ElTRCTOR TO CONNCT THE ABOVE DESCRIBED EXISTING DWELLING �')lv � O I as owner of the property will do the work and the TO THE PUSLIEC SEWER • • • • structure is not intended Or offered for sale (Section SIGNED THIS DAY OF t9 a 7044 Business and Professions Code) OWNER OR l b 2 • • 1 8 0 0 OWNERS AGENT p CONSTRUCTION LENDING AGENCY AGGRESS • • • 1 U Q d c=J I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 1023-80 issued(Sec 3097 Civ C) Lender s Name Lender s Address 1 certify that I have read this application and state that the above information is correct I agree to comply with dll County ordinances and State laws reg u ting Plumbing and Sewers and hereby a thorize repr se Ives of this County to enter upon the ove ntioned pe y for inspects purposes -�? C;;� SEE REVERSE FOR EXPLANATORY LANGUAGE V, Signature—of Perm ttee DaVe