The URL can be used to link to this page

Home My Public Portal About10124 NADINE ST_Sewer__ am Sa88 11 DS APPLICATION FOR PERMIT 8 8 R 8 DrMON OF BURDBIG AND SAFETY SEWER SEWAGE DISPOSAL Deportment ofConntq Engineer County Of 1.06 AngeleB BUILDING y JOHN A LAMBIE COUNTY ENGINEER ADDRESS ® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY FOR APPLICANT TO FILL IN NCR SS ST LEGAL OWNER DESCRIPTION LOT NO MAIL BLOCK TRACT ADDRESS NO OF SLOGS CITY TEL N SIZE OF LOT NOW ON LOT aA 11.9 USE OF DISTRICT NO GROUP MAP BUILDINGS s— BK PG CONTRACTOR O� v g ADDRESS Z d CONNECTION DATA ,CTION CITY �.Q TEL NO � 5i Y� 5 STATION ��e W DEPTH MANHO E EF RENCE UPPER &-STATE REGISTRATION NO Z J ❑ COUNTY L NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM ' HOUSE SEWER CONNECTING TO �� Y CURB M L TO P L PUBLIC SEWER @ $9 50 SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD ® $9 00 OVERFLOW SEEPAGE PIT DRAINFIELD CO IMP NO EXTN CESSPOOL DRYWELL MANHOLE ® $2 00 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM @ $100 TRUNK PERMIT NO ROAD PERMIT NO CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT WORK TO HOUSE SEWER (� $100 PERMIT NO ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM ® $1 00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER S PER= s ] 00 AUTHORIZATION TOTAL FEE J REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER NEW HOUSE SEWER SIGNED THIDAY OF _19 CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGENT SEPTIC TANK SEEP PIT(S) ADDRESS AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ 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 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY S ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 A THE LEGAL OVER OF THE ABOVE DESCRIBED RESIDENTIAL PERTY BACKFILL SEPTIC TANKS❑ SIGNATURE SEEP PITS) [ICESSPOOLS❑ OF FERMITTE JOHN A MBIE CAYNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PBG INSPECTOR CK M C CASH (ACn5 4 8 3 MAR 2'7 4 450 �+ WORKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self Insure ar a cortdmte of WorkersWompItinsatlon Insurance or 76AG42D a certified copy thereof(Sec 3800 Lab C, - 0002DPW 81" APPLICATION FOR PERMIT Policy No Company ❑ 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 SENSE Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE a DDR SSS D�Z w STATION DEPTH bw (This section need not be completed if the work Involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars($100)or less) Locum r L R NEAREST f OM I certify that in the performance of the work for which this CROSS ST 4i i/l e-� Y TYPE CURB ION P L LENGTH ML TO P L. permit is Issued I shall not emplo any pe In any manner v C No s0 ns t0 Om subject to the r� nsation Laws OWNER -n f ('�^. CO IMP NO JOB NO 4q MAIL TRUNK PERMIT NO ROAD PERMIT NO Data ry Applicant ADDRESS NOTICE TO APPLICANT If after making this Certificate of CITY TEL AFFIDAVIT WArvER EAsennENT RECORD INSTR No DATE Exemption you should become subject to the Workers 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 PERMIT No E OF Loi Now ON LOT I hereby affirm that I am licensed under provisions of Chapter USE SE OF 9 (commencing with Section 7000) of Division 3 of the Busl BUILDINGS A%.rr / CHARGES news and Professions Code and my license is In full force and effect CONTRACTOR 04, CONNECTION CHARGE FEE A License Number Lie Class ADDRESSO 2 ry— .� REIMBURSEMENT FEE y8•� Contractor Date DISTRICT GROUP MAP D BY CITY TEL NO I� SK PG El am exempt under Sec of the L A Co STATELIC LICENSE NO sass Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FIHOUSE SMR A AT ON N PUBLIC SEWER CONNECTING TO DA ✓ B 8 P Coda for the following reason SEPTIC TANK SEEPAGE PIT OR Z Date PITS AND/OR DRAINFIELD BY AL IL HOUSE SEWER CONNECTING TO PRIVATE DISIPOSM SYSTEM Signature CONNECT ADDITIONAL BLDG OR ► OWNER BUILDER DECLARATION WORK TO HOUSE SEWER RFLOW I hereby affirm that I am exempt from SEEPAGE PIT DRAINFIELD om the Contractor s License Em CESSPOOL oRYWELL MANHOLE Law for the following reason (Secton 7031 5 Buisness and Pro ALTER REPAIR OR HOUSE fe ns Code) SEWER OR DISPOSAL SYSTEM as owner of thero p party or my employees with wages as their sole compensation will do the work and the structure is not intended or offered for sale (Section 7044 Business Permit i and Professions Code) OWNER'S ❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE �Q licensed contractors to construct the project(Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED 0 /� Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLI At 4T e T CONSTRUCTION LENDING AGENCY , I hereby affirm that there Is a construction lending agency SIGNED THIS !`t 99v 3307 14.00 for the performance of the work for which this permit is OWNER�ACENi3 7 lTv� issued(Sec 3097 Civ C) ADDRESS C 2 ITEMS 00 Lender s Name I ender s Address PTAL 27.OQ I certify that I have read this application and state that the CHECK 27.W above information is correct I agree to comply with all County ordinances and Staln laws regulating Plumbing and Sewers E of and h t I representatives of this County to enter upo t boned property for Inap do purposes �qV 0000-MOI 4/ 4/90 ign ure of Permittee Date SEE REVERSE FOILEXPLANATORY LANGUAGE 9893 2 AM 7:%"J-