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Home My Public Portal About6009 OAK AVE_Sewer__ v 76A642D CE 8081REV.1/78!•-4111( APPLICATION-FOR E RM IT os SEWER - SEWAGE DISPOSAL COUNTY OF LOS ANGELES BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT NO. GROUP MAP PR CESSED BY BK PG t BUILDING / / Q ) ADDRESS I .G LOCALITY CONNECTION DATA NEAREST / STATION DEPTH CROSS ST. `7 rC UPPER MANHOLE REFERENCE LOWER OWNER TYPE OF CONNECTION LENGTH FROM MAIL Y. CURB P.L. M.L.TO P.L. ADDRESS _ P.C.NO. F' j j- �G _ O CO.IMP.NO. JOB NO. CITY EL.NO. Oo LEGAL TRUNK PERMIT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE BLOCK TRACT NO.OF BLDGS. SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING USE OF BUILDINGS STATE ENCROACHMENT PERMIT NO, CONTRACTOR E INDUSTRIAL WASTE APPROVAL ADDRESS CHARGES CITU TEL.NO. CONNECTION CHARGE FEE STATE LIC. REIMBURSEMENT FEE LICENSE NO. CLASS NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE y HOUSE SEWER CONNECTING TO PUBLIC SEWER SEPTIC TANK.SEEPAGE PIT OR NEW HOUSE SEWER PITS AND/OR DRAINFIELD CONNECT ADDITIONAL HOUSE SEWER CONNECTING TO BUILDING OR WORK U. PRIVATE DISPOSAL SYSTEM SEPTIC TANK.SEEP,PIT(S) CONNECT ADDITIONAL BLDG.OR / 7'�I AND/OR DRAINFIELD WORKTO HOUSE SEWER (��/ OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ClDRYWELL❑ E XTN.,CESSPOOL.DRYWELL,MANHOLE ALTER.REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS❑ OWNER'S Permit $ SEEP.PITIS)❑ CESSPOOLS❑AUTHORIZATION VALIDATION TOTAL FEE C7 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. ;F9 0 f 0 A SIGNED THIS DAY OF 19_ y OWNER OR # • • • • 1 0 OWNERS AGENT ADDRESS 2 • • 1 0 C IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - - AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY T- • 1 C' it WITH ALL COUNTY ORDINANC AND STATE LAWS REGULATING PLUMBING AND SEWERS. - 1 HEREBY CERTIFY THAT M PROPERLY REGISTERED AND/OR Q 0-80 8 0 LICENSED AS REQUIRE S ANGELES COUNTY STATE OF Ci CALIFORNIA OR THAT 1 LEGAL OWNE OF.A N ND TO RE- SIDE IN,THE ABOVE D BED RESIDENTI PRO RTY SIGNATURE OF PERMITTE WORKERS COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self. Insure or a certificate of Workers Compensation Insuillnce or 76A642D a certified copy thereof(Sec 3800 Lab C) CE=tREV 1101 APPLICATION FOR PERMIT Policy No Company [I 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 Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILDING STATION DEPTH COMPENSATION INSURANCE AaoREa /R e (This section need not be completed if the work involved by the LOCALITY MANNOSE REFERENCE permit Is for one hundred dollars(=100)or less) NEAREST I certify that in the performance of the work for which this CR �� K3N FROM permit is issued I shall not employ any person m y manner r P t MM LL T TOPPI. L NO so as to become subject to the W n=9ah laws O �i /KJ IMP �NO (r MAIL 9W Q,oTRUNK PERMIT NO ROAD PERMIT NO /r DaroAppticant ^pro NOTICE TO APPLICANT If after maks this Certificate of CRY a� Ug AFFIDAVIT—7 EASEMENTRECORD INSTR NO GATE Exemption you should become subject to the Workers LEGAL OF Compensation provisions of the Labor code you must forthwith DESCR1PrION LOT NO HWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked "' BLOCK TRACT STATE 04CROACHAAEW LICENSED CONTRACTORS DECLARATION PERMITNO SIZE OF Lot Now ON LOT hereby affirm that I am licensed under provisions of Chapter BJ** (commencing with Section 7000) of Division 3 of the Busi BUILDINGS RGS pipes ness and Professions Code and my license Is in full force aryl effect CONTRACTOR CONNECTION CHARGE PEE License Number Lic Class ADDRESS RE NT FEE Contractor Date CRY DISTRICT NO GROUP MAP4VAL SED BY V V ❑ 1 am exempt under Sec of the L A Co LICENSE NO CTE CAs O � Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK FEE p s NOUN SEWER CONNECTING TO DATE ON W B 8 P Code for the following reason PPUBtISEPTICTANKRSEEPAGE PIT OR F1NAl PRS AND/OR DRAINFIELD Date !OUSE SEWER CONNECnNG,TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER BUILDER DECLARATION WORK TO HOUSE SEWER FLOW LS 1 hereby affirm that 1 am exempt from the Contractors License XIN CESSPOOL DRrAGErawELt�teMANHOLE Law for the following reason(Secton 7031 5 Buisness and Pro ALTER REPAIR OR ABANDON HOUSE Ions Code) SEWER OR DISPOSAL SYSTEM 1 as owner of the property or myemployees with wages as 16 7 2 R their sole compensation will do the work and the structure #s e s s s 1 C Is not intended or offered for sole(Section 7044 Business Perrntt : 2 sus and Professions Code) OWNER'S 7 5 0 ❑ 1 as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE (�4 licensed contractors to construct the project(Section 7014 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED TO ' Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER !]i C 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 OWNERS AGENT Issued(Sec 3097 Civ C) Lender s Name ADDRESS Lender s Address 1 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 herelyLpauthorize esentatives of this County to enter u the In I.on property for inspection purposes /41 Signatu of Ittee 1111111 MVM FOR OWLARAT02Y LANOUAOE