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Home My Public Portal About9929 LOWER AZUSA RD_Sewer__ ,6A"2D APPLICATION FOR PERMIT 8 Sc E.663 11.55 1 , DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL. y Depmfti nt of County Engineer County of Los Angeles BUILDING /al 3 v . JOHN A. LAMBIE,COUNTY ENGINEER ADDRESS !� ® GASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NEAREST. LEGAL OWNER DESCRIPTION LOT NO. MAIL / BLOCK TRACT ADDRESS I '� NO.OF BLDGS. ff/ SIZE OF LOT NOW ON LOT CIT TEL. NO tV USE OF DISTRICT NO. GROUP MAP BUILDINGS d - I I PG Mj CONTRACTOR i ADDRESS � �, CONNECTION DATA STIr ATION DEPTH CITY �- CITY EL. O. �., O MANHOLE REFERENCE C► OW REGISTRATION NO. ❑ COUNTY No. DESCRIPTION OF.WORK FEE TYPE OF CONNECT LENGTH FROM HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. (o PUBLIC SEWER @ $3.50 0 SEPTIC TANK,SEEPAGE PIT OR PITS AHD/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD P. C. NO. EXTN.,CESSPOOL,DRYWELL•,MANHOLE @ S 2.00 CO. IMP,NO. O JOB NO. HOUSE S1ER PRIVATE DISPOSAL SYSTEMG TO @ $1,00 TRUNK PERMIT NO. '�- ROAD PERMIT NO. !140n4 CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT WORK TO HOUSE SEWER ® $1:00 VQ PERMIT NO. ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'SPEILMT S 1 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN ffEN APPROVALS DATE IN PECTOR'SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTIN TO THE PUBLIC SEWER. I NEW HOUSE SEWER %VIA _{ SIGNED THIS DA OF 19 CONNECT ADDITIONAL OWNER OR --17 BUILDING OR WORK OWNERS AGENT L..L �� •7T�� `� SEPTIC TANK,SEEP,PITS) ADDRESS AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL Cl 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 I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TA S❑ SIGNATURE SEEP.PIT(S) ❑ CES OF PERMITTEE JOHN A.-LAM®IE.COUNJY ENGINEER VALIDATION ROBERTA. WOOD.CHIEF PLBG. INSPECTOR low CK. M.0. CASH - � I` 7553,- Am,26. - 4 5.5Q L WORKERS'COMPENSATION DECLARATION P'heleay affirm that I have a certificate of consent to self insure, or o 2ertiTicate of Workers'Compensation Insurance, or 76'`8''2° %POCI ertified cop thereof(Sec. 380, Lab 626002oPw6,66. APPLICATION FOR .PERMIT icy No "Company �`� t^.4P1N1, Mf% Certif copy Is hereby furnished.Ir151�0mv (SAV SEWER - SEWAGE DISPOSAL ❑'Certified copy'is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY de rtment. . Dote�Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEM ION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDRESS g s STATION DEPTH (This section need not be completed if the work involved by the LOCnI +�. MANHOLE REFERENCE UPPER permit is for one hundred dollars($100)or less.) t�AREST TYPE OF CONNECTION LENGTH FROM certify that in the performance of the work for which this c�OSSST. . Y. CURB PA. 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. OWNER ` /��y415N P.C.NO. ° CO.IMP.NO. !OB NO. MAIL Date Applicant LAS -MIJA ADDRESS , ° �° TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE, TO APPLICANT: If, after making this Certificate of CIT �• . AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE Exemption, you should.'become subject to the,Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. "jr HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION /� C NO.OF BLDGS. PERMIT NO. SIZE OF LOT 2 ]- F NOW ON LOT UQJJ I hereby affirm that I am licensed under provisions of Chapter USE OF �j 9(commencing with Section 7000) of Division 3 of the Busi- BUILDINGS }.198 p •&L., CHARGES .ness and Professions Code, and my license is in full force and effect. / f CONTRACTOR ' � ° CONNECTION.CHARGE FEE License Number\ i; 1�'1 Lic.Class l�� ADDRESS REIMBURSEMENT FEE S /i°' Contractor `'�.y Date - -J.o,NPG DISTRICT NO. GROUP MAP - SSED BY CITY TEL.NO. BK ❑ I am exempt under Sec. of the L.A.Co. L' NSE,p• CCCSS Plumbing Code and/or Sec. of the No. OESCRIPTION OF WORK FEE FINAL UO oo�A yaj HOUSE SEWER CONNECTING To DATE —_/,y�� _1 VALIDATION N PUBLIC SEWER tC;T B. 8 P. Code for the fallowing reason SEPTIC TANK SEEPAGE PIT OR FINAL r ? PITS AND/6k DRAINFIELD (2 Date HOUSE SEWER CONNECTING TO BY (� 1-w✓' PRIVATED1 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 OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN. CESSPOOL,DRYWELLMANHOLE Low for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR AtANDON SYSTEM HOUSE �I fessions Code): SEWER OR DISPOSAL ❑ I,as owner of the property,or my employees with wages as ACCT.v their sole compensation,will do the work and the structure , is not intended or offered for sale (Section 7044, Business `M- 7 34°•-k�c-1 and Professions Code). OWNER'S Permit 5 S AUTHORIZATION 1 ITEM ❑ I,as owner of the property,am exclusively contracting with TOTAL FEE jy[' —a licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO TOTAL +-�14 .50 Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY CHECR 34.% 1 hereby affirm that there is a construction lending agency SIGNED THIS a D Y OF +-qDOWNER OR •— CHANISE ■��l for the performance of the work for which this permit is OWNERS AGENT issued (Sec. 3097, Civ. C.). �•. ADDRESSt:_' Lender's Name . 00(]17-0001 2/. 7I9! Lender's Address 5529J.:c2 , 2 I certify that I hove read this application and state.that the Q 1 Ahs' [Iz° 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