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Home My Public Portal About5324 MCCULLOCH AVE_Sewer__ �e=. Haag °_�2 `APPLICAT14N FOR PERMIT '6A6.420 COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING" TO Ii A. LAMB.IE, County Engineor ADCRE..J� �3 .� --�, C l..t' ,t..�=°' i.,�' WILLIAM A. JENSEN, Sup't of Building t+� t" LOCAL I7Y N ARE T -- -- -- - FOR APPLICANT TO F IN D p '-S1l I C1 O J OWNER :a�, Lam' -1 � ' MI I_ a q 3I.CC rS TRACT _' ® ADDRESS ' °�"'Y��,'E_ �=1 p�.6�L �- NO. OF SLDGS. .. -c O OT FUW ON L7Y CITY �"�" TEL. NO. USE- L NG,, w- - DISTRICT NO. GROUP B?c MAP .PRQrESSED BY _ COr1TRt ,.rCiR_ _ .f - ,✓C.,�-`�,v^o,.""`"''� ,r zP �j �.r'',f',' ./..Y'y✓�lf ADDRESS — —f y'` j" � �f"".. CONNECTION DATA [.__ - _ -.._TEL NO: �' ,/��4. r'E' `T STATOt`i --.- —__ _- DFFTH___. �++ :+ �„ STATE MANMCILF ReF£f7 '7 E NCF�`� tG!STATIJN NO +g„' CC �NTY LOWEa -_ ___ -�__ a. LJESCRIPTipH OF WORK FE _ -- - -- - 0 __ _ _ TYPr�OF CQNNt+-NF(-TION LF FROM I HOUSE SEWER CONNECTING 70 Y / yp g^U,-a / P F�. 1�$.L 10 P.L. PJ BLIC SEWER @ $6.00 Cie SEPTIC TANK,>EE PAGE P7T OR - _-- � i 9� - PITS AND/OR DRAIN FIELD CU 1MP NU. JOB NO... HOUSE SEWER COri NEr7'i NGy TO , TRJNK PERMIT NO. ROAD PERMIT NO, PRIVR7E D S C A.L SYSTEM L $3 00 I 1 Liu —' CONNECT ADDITIONAL.IONA� SLOG OR V AFFIDAVIT b4:41VE& cFSENE F RE'COriO.INST NO DATE _ a I Vll RK C HOUSE SEWER @ $i.Oq I OVERFLOW SEEPAGE PIF,DRA7NFIELD ...- __-___ k XTN GESSpnOt_,pRYW ELL,P4A'iNOL€@ $5.C?Q ' r --1 --._ __-- HWY.OR Sr.WIDENING ALTER.REPAIR OR ABANDON HOUSE $EWER.OR DISPOSAL SYSTEM �._._._ I PERMIT NO' INL'U�FRYAL - WA STE APPROVAL - OvIlm $' PERMIT — zL 00 Lr.ARGc -- AUTHORIZATION TOM EE �I CONNECTION CHARGE FEE I HAVE Af THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO Cb"A 1`tlEC:Y Td-0E ABOYE DESC;RI SED EXISTING DW EL.LINv ------ --- ---y`----------e-- ----I --------- ---- YO THE PUBLIC SEWER. APPROVALS i DATE I INSPECTOR'S SIGNA"URIF SIGNED THIS_—.. .DA.Y OF.---,-----------'9- - O`f(PdERCP N WHOUSE.SEWER _:---.--_--_;'— _. OWNER S A(i E'P!T__� -._ _._ . _ONNECf ADDITIONAL ADDRESS BUILDING OR WORK ---._- -----------__.O TANK.SPEY Pi (S; I HEREBY AGK+JW_.E4+cnE THAT i HAVE READ THIS APPLICATION AM ANO L'i `i ORA]t�.d}�1 LD ' .AND STATE THAT THE.ABOVE. 15 CORRECT AND AGREE TO COMPLY WITH ALe,. COUNTY ORDINAN•CFS AND STATE LAWS REGULATING PLU Mai Nu AND SEW ER5. CESSPOOL ORYWEL.L [1 I HERESY CERTIFY THAT '. AM PROPERLY REGISTERED AND/OR A._.TER,REPAIR SEWER�O Fi- ---i-_----.�I___------_-----~_--- L.ICE.N9EU AS REQUIRED BY LOS ANCLE.S COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM I CALIFORNIA OR THAT I AM THE LEGAL.OWNER OF, AND INTEND TO RESIDE IN, THE ABGV. O CRiBFD RESIDENTIAL PROPERTY. DISCONNECT PLUG AND ABANDON HOUSE SEWER SIGNA'TURE W OF PERMITTEE BACY.F! 'FF Y!c. IANKS -.._.-_.._-- �"Zt` SEEP.PiTISi LI CESSPOOLS — VALIDATION------, ROBERT A. WOOD °. SUPERVISING MECHANICAL ENGINEER 2. . 8 9 V f�G' AUG 1 41 0 D 5.0 C) P WORKERS'COMPENSATION DECLARATION I hereby affirm that"1 have a'certificate of consent to self insure, or 6 certificate of`(Yorkers'Compensation Insurance, or 76A602D a cgrirified copy thereof (Sac. 3800, Lab C.) ez-ocozDPW s ee APPLICATION FOR PERMIT Pgiicy No. Compony ❑ Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING ' ' ' "f COMPENSATION INSURANCE ADDRESS �� , = �e L `� i 3 t-. I� '� STATION DEPTH (This section need not be completed if the work involved by theMANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOCALITY LOWER NEAREST �'3 TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CRO_ST. — 7 Y, P.I. M.L TO P.L. permit is issued, I shall not employ any person in any manner CtxtB'' t' i so as to become subject to the Workers'Compensation Laws �� +-'; a P.C.NO. OWNER ��F�i C,.%Qj�,. - -� I CO.IMP.NO. JOB NO. MAIL Date Applicant sF,? ADDRESS p _ TRUNK PERMIT NO. ROAD PERMIT NO. NOTICE 10 APPLICANT; If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.INSTR,NO. DATE CITY \ �� 1,l, TEL.NO. 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.SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter TSE 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 J 'f ,I L CONNECTION CHARGE FEE License Number _Lic.Class ADDRESS + REIMBURSEMENT FEE Contractor Date DISTRICT NO. GROUP MAP PROCESSED BY !z CITY i4' TEL,NO. BK PG _ v ❑ I am exempt under Sec. �of the L.A.Co. LCELIC. NO. CASS Plumbing Code and/or Sec. of the No. DESCRIPTION OF WORK FEE FINAL W HOUSE SEWER CONNECTING TO / r1 DATEPUBLIC SEWER - VALIDATION Z B. 8 P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR l PITS AND/OR DRAINFIELD F'NAL Date HOUSE SEWER CONNECTING TO BY PRIVATE DIS SAL SYSTEM 2 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 Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 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 sole (Section 7044, Business and Professions Code). OWNER'S Permit y 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 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 she above-mentioned property for inspection purposes. Signature of Per'inittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE