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HomeMy Public PortalAbout5317 NOEL DR_Sewer__ o mooa sa Ba APPLICATION FOR PERMIT 1 ct COUNTY OF LOS ANGEM SEWER—SEWAGE DISPOSAL DEPARTMMW OF COUNTY ENGDOM DUMDING AND SAFETY DNMON BUILDING TOM A. Lam. Com 8n� ADDRESS CII UTT D G8UTM Sup t of 3whHeQ LOCALITY NEAREST FOR APPLICANT TO F= IIsi cross si LEGAL DESCRIPTION LOT NO OWNER BLOCK TRACT RAIL V ADDRESS / NO OF ILL SIZE OF LOT NOW ON LOT CITY TEL NO USE OF BUILDINGS DISTRICT NO GROUP NAP P CESSED BY BR PG CONTRACTOR ADDRESS CTION DATA CITY TEL NO STATION DEPTH REGISTRATION 0 COUNTY MANHOLE REFERENCE UPPER No DESCRIPTION OF VORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER 3 00 TYPE OF ION LENGTH FROM SPITS AND/OR DRAINFIELD T OR 300 Y CURB P L Y L TO P L OVERFLOW SEEPAGE PITT DRAINFIELD EXTN CESSPOOL DRYWELL MANHOLE G $2 00 HOUSE SEWER CONNECTING TO P C NO PRIVATE DISPOSAL SYSTEM $100 CO IMP NO JOB No CONNECT ADDITIONAL BLDG OR TRUNK PERRIT NO ROAD PERMIT NO WORK TO HOUSE SEWER 100 SEWER OR DISPOSALBSAYSSTEM HOUSE $1 OO STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNERSPERMT S 00 CONNECTION CHARGE FEE AZITROBMATION TOTAL FEB REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR 8 SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIED ISTING DWELLING TO THE PUBLIC SEW - SIGNED TH! AY OF is-�e� NEx►xousE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK BETADDRES AND/RTDRAINFIELDPIT(S) ACKNOWLEDGE THAT 0 -d.- ipp-malon ANSTATETHAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY CESSPOOL 13 DRYWELL 13 LDESCRIBED LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR G AND SEWERS SEWAGE DISPOSAL SYSTEM EBY CERTIFY THAT 1 AM PROPERLT REGISTERED AND/OR DISCONNECT PLUG AND D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER NIA OR THAT 1 AMtEIL OWNER OF THE ABOVE RESIDE T PROP BACKFILL SSEPTIC CA�� / OLS 7. M MI ( AnON ROBERT A WOOD M B! "a SUPERVISING BISCH"IC,AL BNGINSMR: 33S8A (ET �, �, 0A 5d0 e 9-- wro, ORKERS COMPENSATION DECLARATION Irm,that 1 have a certificate of consent to self ertificate of Workers Compensation Insu a or 76A642D a certified coy er f(Sec 3eoo,lieb ma �I APPLICATION FOR PERMIT Policy No �rlpany Certified copy is hereby furnished SEWER - SEWAGE DISPOSAL Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY Dot. a Applicant xrg t) 441— 0e-5PAMDRESS FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE X STATION oEPnt (This section need not be completed if the work involved by the C:� MANHOLE REFERENCE UPPER permit is for one hundred dollars($100)or less) LOCALITY OM I certify that in the performance of the work for which this © TYPE OF CONNECTION M L TO P IL Y CURB PL ML TOPL permit is issued I shall not employ any person in any manner PC NO so as to become subject to the Workers Compensation Laws A /� R�rJ (�(/u CO IMP NO JOB NO MAIL ' ' TRUNK PERMIT No ROAD PERMIT No Date Applicant NOTICE TO APPLICANT If after making this Certificate ofclry G. NO 8�.S3i 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 HWY OR ST WIDENING comply with such provisions or this permit shall be deemed Gr revoked BLOCK G TRACT STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION NO OF BLDGS PERMIT NO I herebyaffirm that I am licensed under provisions of Chapter SIZE OF LOT Now ON LOT 9 (comencing with Section 7000) of Division 3 of the Busi USE CHARGES ness and Professions Code and my license Is In full force and effect �j��� CONTRACTOR T V r CONNECTION CHARGE FEE �License Number 5LIC Class ADDRESS REIMBURSEMENT FEE d Contractor.7 A&IdA a1VP CITv • v� TEl NO DISTRICT NO CROUP MAP PROCESSED BY Q ❑ I am exempt under Sec of the L A Co LICENSE NO / CLA55 I .1 l� M 10-31 VO Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE FINAL HOUSE SIEWER C SEWER CONNECTING TO DATE VALIDATION d B 8 P Code for the following reason SEPTIC TANK SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINA Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR Q OWNER BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractors License EOXTNF�CESSPOOL DR PAGE IYWELLAIMAN OLE Law for the following reason(Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE fesslons 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 sale (Section 7044 Business Permit S 2 3 7 6 3 A and Professions Code) OWNER S62 ❑ I as owner of the property am exclusively contracting with AUTHORIZATION I TOTAL FEE Jt J4 JT # • • • • 0 licensed contractors to construct the project (Section 7044 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO o -2150 Business and Professions Code) CONNECT THE ABOVE DESCRI D EXISTING G_TO THE PUBLIC SEWER CONSTRUCTION LENDING AGENCYQ� • ;WNERS •21505 1 hereby affirm that there Is a construction lending agency SIGNED THDAY for the performance of the work for which this permit is GO ' OR 06-86 Issued(Sec 3097 Civ C ) ADDRE 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 o nces and State laws regulating Plumbing and Sewers a hereby authorize representatives of this County to enter u on a aboventioned property for Inspection rposes nature rmittee /0.,:?W Date SEE REVERSE FOR EXPLANATORY LANGUAGE