The URL can be used to link to this page

Home My Public Portal About4964 MCCLINTOCK AVE_Sewer__ DEP"fKENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 3 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEERI BUA ILDING /! ��,w, �C ADDRESS (� FOR APPLIQANT TO FIL-LLOCALITY BUILDING _ CROSS ST. r- G( ADDRESS ,f ,I LOCALITY DISTRICT 06 SERIAL NO. PERMIT NO. NEAREST `✓ A L?%450'sCROSS ST. EIV D'BY Reidy for Inspootieo /DATE ISSUED OWNER v►. !fes, ES'�/� MAIL � U$FgLZ NE OOCUPAN S fiJCY / MAP ADDRESBK PG CITY TEL.NO. CON.TRACTOIC lifonnia 56waf-Const.co. CO.IMP.N0. ADDRESS . . 7 Coleg oVe AVb• JOB NO. CITY M t"?te-hello TELANNion I-5048 TRUNK PERMIT NO. STATE REGISTRATION NO�04445 S'Gc�i`,49UNTY: ROAD PERMIT NO. LEGALSTATE ENCROACHMENT DESCRIPTION LOT N0. PERMIT NO. BLOCK TRACT WASTE APPROVAL SIZE OF LOT14 5 NO.OF BLDOS. NOW ON LOT CHARGES USE OF BUILDINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE AHREIMBURSEMENT FEE HOUSE SEWER CONNECTING TO "]y PUBLIC SEWER S 3.50 LL++ RECEIPT NO. I DATE I BY OUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO HOUSE SEWER 1.00 ALTER OR REPAIR EXISTING NC- I DATE BY SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR PITS.AND/OR DRAINFIELD 2.00 STATION CESSPOOL—ORYWELIL �_ D DEPTH SPECIAL CONDITIOIAS ONLY 2.00 MANHOLE REFERENCE � IV J- LOWER TYPE OF CONNECTION - LENGTH FROM OWNERS PERMIT ; 1 00 Y. cults P.L. M.L.TO P.L. AUTHORIZATION I TOTAL FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING- APPROVALS INSPECTOR-S.SIGNATURE DATE DWELLING TOT E PUBLIC SEWER SIGNED THIS__kf.�!.. MAY OF6 / _.._. 14NEW HOUSE SEWER /�� Ay, :�c OWNER ORCONNECT ADDITIONAL OWNERS AGE T .... ..,. .._ _......• _. _.:..._. BUILDING OR WORK ADDRESS. . " ! -/� EPTIC TANK.SEEP.PIT(S) - - -.. . _.. - - _...._... -T� D/ORDRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0.DRY WELL:[]. CATION AND STATE THAT THE.ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING:P.LUMBINO AND SEWERS. SEWAGE DISPOSAL SYSTEM r1 9EERTIFyYF;TH+i4T 11 "M PROPERLY'REGISTERED ArNO/.OR�pLICE,N$ED�+AS REQUIRED"-BY:.LOS-:ANGELES COUNTY DISCONNECT PLUG AND ABANDON HOUSE SEWER J ND'87ATE�:O,F OALIF.ORN1 ^OR`THAT 1 AM'THE LEGAL OWN- �. 'OF-;-.THE;-A'BOVE'Q.ESCR BED pESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS 1 I // SEE,P.PIT(S)�-:CESSPOOLS° f. SIGNATURE OFPERMITTEEJ�!A. .. � � � ;. ;,.:- •. .. - 78A648D 863 1/63 r. i4 -`�s J-ORKERS'tCOMPENSATION DECLARATION IIt�. ?fftlm that'j},'have .a-certificate of consent to self I7 .+Haute, aF a certifi)rate of Workers'Compensation Insurance, or. 76AA42D a certified copy thereof(Sec. 3800,Lgb C'.) -As � CE8081REV 1:831 APPLICATION FOR PERMIT P Ile Na. _ Company r'ti ! SEWER - SEWAGE DISPOSAL Certified copy Is hereby furnished. ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. ate �� Applicant. �r�� G 9S7" FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ( STATION DEPTH b COMPENSATION INSURANCE ADDRESS' At 6if Up (This section need not be completed if the work involved by the iOC�4 MANHOLE.REFERENCE J Ali permit is for one hundred dollars'($100)or less.) LOWER I certify that in the performance of the work for which this NEAREST TYPE OF CONNECTION GTN FROM /1 permit is issued, I shall not employ an `!. CURB L LTO PJ. V p p y y person in any manner , so as to become subject to the Workers'Compensation Laws. P.C.NO. I P OWNER „,S , CO.IMP NO. JOB NO MAIL Date Applicant ADDRESS TRUNK PERMIT NO ROAD PERMIT NO. NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO. DATE CITY � f TEL.NO. '� / J'o�� 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 LICENSED CONTRACTORS DECLARATION ! NO OF BLDGS PERMIT NO. I hereby affirm that I am licensed under provisions of Chapter SIZE OF LOT NOW ON LOT USE of � I 9 (commencing with Sec1i.OTj 7000) Of Division 3 Of the BUST- BUILDINGS /: CHARGES ness and Professions Code, and my license is in full force'and effect. CONTRACTOR . .� �„� CONNECTION CHARGE FEE • License Number. Lic.Class ADDR REIMBURSEMENT FEE 4 Contractor, Date ' :,p�j DISTRICT NO GROUP MAP PROCESSED 8Y O CITY TEL.NO �/ STATE LIC. Bk PG ❑ 1 am exempt under Sac.. of.the L.A.Co. LICENSE„NO. CLASS Gjig Ly 0 NO, DESCRIPTION OF WORK FEE Plumbing Coale and/or Sec. . of the FINAL ri *MUSE SEWER CONNECTING TO DATE ! VALIDATIO IIY PUBLIC SEWER. B. &P. Code for the following reason SEPTIC TANK,.SEEPAGE PR 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 OVERFLOW SEEPAGE PIT,DRAINFIELD . I hereby affirm that I am exempt from the Contractors License ExTN,CESSPOOL,DRYWELL.MANHOLE Law for the following reason(Secton 7031.5,,Buisness and Pro ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM' J? 1 0 ek,t A fessions Code): U J ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure ,t V 'D o o () isnot intended or offered for sale (Section 7044, Business and Professions Code).: OWNER'S Permit S I o o 1 7.5 0 ❑ 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'C ACT TC o O O �, Q Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency SIGNOWNEED THISDAY OFr2i! 1 , for the performance of the. work for which this permit is R OR issued(Sec. 3097, Civ..I C.). OWNERS AGENT L 9 Lender's Name /6 ADDRESSO 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 pr sentatives of this County to enter upon the above•m d roperty for inspection purposes. Signature 0r Ittee Date T SEE REVERSE FOR EXPLANATORY LANGUAGE