HomeMy Public PortalAbout10526 OLIVE ST_Sewer__ 76AS4213 - APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles 13UILDSSGADDRE ,. zj. r
J0!-!N A. LAMBIE, COUNTY ENGINEER --
CASSATT D. GRIFFIN, SUPT OF BUILDING -LOCALITY
FOR_APPLICANT TO FILL IN CROSS s,
LEGAL
D.ESCRlPTIONLOT N0. - ,��- ---_- —�-- OWNERyt._, .3
_ —._ - -_- -y--�
BLOCK TRACT MAIL
f ,7ADDRESS
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�. �v CITY TEL. NO.�^+- - •�.i. .
SiZE_OF LOT �.i? - y a� NOW ON LOT 'C
i
USE OF'
BUILDINGS- .-ia,>.[.,. �,,_,((t D-ISTRICT NO. 4� GROUP BK MAP PG
CONTRACTOR -.-------.- d--Y
----- --_._
ADDRESS CONNECTION DATA a
._. ------ ------------- _ -- -__- ._-._--
STATION DEPTH ` ✓''� •'""
CITY -"° -
---'— --,�-- _------ ---- MANHOLE REFERENCE _, ,y:: y $ UPP1<:.R
L7 STATE _ -._._.---- °�.,� ...,✓._- _'� .'-:_r -L-trtrEK-�
REGISTRAILQ_N_wcS ----- _. [] COUNTY -
NO• ! DESCRIPTION OF WORK FEE ----------- -------------- --------
-- i TYPE OF CONNECTION - LENGTH FROM
HOUSE SEWER CONNECTING TO �� Y. CURS L. M.L.TO
_PUBLIC
SEWERC� $3.50 - �� — --- --�--_�+- -SEPTIC TANK,SEEPAGE PIT OR
_ _P TS AND/0R DRAINFIELDCw $3.00 -
OVERFLOW SEEPAGE PIT DRAINFIELD I -- `-- - j + P. C. N0,
_ EXTN.,CESSPOOL,DRYWELL,MANHOLE q CO. IMP, NO, r� 10B NO.
$_ C0_ TRUNK PERMIT N0. � ROAD PERMIT NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM (n
CONNECT ADDITIONAL BLDG,OR i S":ATE ENCROACHMENT
I WORK.TO HOUSE SEWER (4 S 1.0O j P';RM_IT NO_.____
ALTER,REPAIR OR ABANDON HOUSE
INDUSTRIAL
I SEWER OR DISPOSAL SYSTEM z .p 1.00 j _! WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ _ t - 00— — --_-_.—__ _-----____--
REIMBURSEMENT.FEE
AUTHORIZATION --TOTAL FEE _
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED APPROVALS CON- DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I
TO THE PUBLIC SEWER. NEW HOUSE SEWER '
SIGNED THIS _DRY OF
..-1�--_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK {
OWNERS AGENT -- SEPTIC TANK,SEEP,PITS)
ADDRESb� AND/OR DRAINFIELD
I HLREBY ACKNOWLEDGE THAT 1 HAVE READ T141S APPLICATION
AND STATE THAT THE ABOVE iS CORRECT AND AGREE TO COMPLY CFSSPOOL[] DRYVIELL��
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL_SYSTEM J i
I HEREBY CERTIFY THAT i Ah{ PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND ------ ----_--- --
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OW
NER``OF THE F�30V£ __ __ __--------- ---.�
DESCRIBED R>=•SIDEN-11,1 lj2UPER1'Y. BACKFILL SEPTIC T ANKS J
�r ;� SEEP.P+l(SD :�I CESSPOOLS.
SIGNATURE ' ;/ -> -- - - - -- -.-'�-z_-
OF PERMITTEE" ,,-�-
JOHN A. LAMBIE, COUNT ENGINEER VALIDATION ROBEF2; A. WOOL), CHIEF' PLEIG. INSPECTOR
CASH
4 5 3 S i}JAi- 1f1�7
4
A, 5 ;
ma�
A
PORKERS'COMPENSATION DECLARAYION
I hereby ciffirm that I have a certificate ofr cor�ent ,to self
insure, or a certificate of Workers'Compensation 1,S rice, or I 76A642D
a certified copy thereof(Sec. 3800, Lab C.) • CE Boa(REV.8/811 APPLICATION FOR PERMIT
Policy N. Company es
❑ Cer ified copy is hereby furnished.
SEWER - SEWAGE DISPOSAL
❑ Ce/ified 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 . A' +" a r STATION DEPTH
COMPENSATION INSURANCE ADDRESS � ee, L` a �`
/Exemption,
its section need not be completed if the work involved by the LOCALITY I�d`j=d JAC .f �c MANHOLE REFERENCE LOWER
His for one hundred dollars($100)or less.)
NEAREST TYPE OF CONNECTION LENGTH FROM
ertify that in the performance of tho work for which this CRO55$T. � d=� v cuRe P.L. M L TO P.L.
mo is issued, I shall not employ any person in any r. onner y P.0 NO. t6
as to become subject to the W rke�jCor�pensatign` `aws. owNER A d fcE� Aelaz-c;� CO.IMP NO JOB NO. 0
�I- Cr X15 6f/ ® TRUNK PERMIT NO ROAD PERMIT NO c Applicant des. � f � � . AMESS IflTICE TO APPLICANT.- If.,. after m kin this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORLI.INSTR:NO DATE9 CITY TEL NO.you should become subject to the Workers' LEGAL ELI
mpensation provisions of the Labor code,you must forthwith DESCRIPTION LOT NO. HWY.OR ST WIDENING
mply with such provisions or this permit shall 'be deemed i6t
revoked. BLOCK TRACT STATE ENCROACHMENT
LICENSED.CONTRACTORS DECLARATION NO OF BLDG$. PERMIT NO
SIZE OF LOT ,NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter USE 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
CONNECTION CHARGE FEE
effect, CONTRACTOR
License Number Llc.Class ADDRESS REIMBURSEMENT FEE.
Contractor .Date DISTRICT NO GROUP MAP PROCESSED BY
CITY TEL.NO �— BK PG
❑ 1 am exempt under Sec. of the L.A.Co. LICENSE NO LIC.
�' � t ru of
Plumbing Code and/or Sec. of the. NO DESCRIPTION OF WORK FEE FINAL
HOUSE SEWER CONNECTING TO DATE VALIDATION.
B. 8 P. Code for the following reason A PUBLIC SEWER LOW
SEPTIC TANK,SEEPAGE PIT OR FINAL
.PITS AND/OR DRAINFIELD FIFI
Date HOUSE SEWER CONNECTING TBY
O
PRIVATE DISPOSAL SYSTEM
Signature CONNECT ADDITIONAL BLDG..OR ® 1
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD
I hereby affirm that 1 am exempt from the Contractor's License EXTNi,.CESSPOOL,DRYWELL.MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
fessions Code):
SF.W.ER OR DLSPOSAL SYSTEM
1,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
and Professions Code). OWNER'S Permit $ ® IPO
❑ 1,.as owner of the.property,am exclusively contracting with: AUTHORIZATION TOTAL.FEE 1-2-1
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). I CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency l SIGNED THIS DAY OF 19_
NER OR 1>
for the performance of the work for which this permit Is I CIA, $AGENT
issued (Sec. 3097, Civ. C.). ODDNESS
Lander'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 i
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representat' .es of this County to enter
upon.lhe above-inentiongd prop for i action purposes.
Sign . re of PeAn ittee Date. SEE REVERSE FOR EXPLANATORY LANGUAGE