HomeMy Public PortalAbout9083 OLIVE ST_Sewer__ DEPARTBEMW OF COUNTY ENGINELI•R SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
{ WILLIAM J. FOX, COUNTY EN13INEER BUILDING
ADDRESS f7 '
FOR APPLICANT TO FILL INBUILDLocau7Y l ,f
ADDRESS ��p� Z,�d 1/e S NEAREST /{ I f)C//7/.r o /"LM
CROSS ST. �// /7L� r-
LOCALITY 7(-/pJ p/LD DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A ll(. 2 �5q57 S
CROSS 57., E j h c * RECEIVED BY Ready for Inspection DATE ISSUED
OWNER dEpp'/7 r��///h fj
��- 3��j--� �•q / �
ADDRESS 9MAIL
L�a 3 6,Ll// tr�C� 3 �! USE ZONE OCCUPANCY MAP
BK PG
TTY TEL.NO. l� �_ r S'
CONTR ORS` CO.IMP.NO. 1:377-2— e--
ADDRESS
JOB.N0.
CITY TEL.NO. ���� TRUNK PERMIT NO.
STATE
R RATION NO. ® COUNTY ROAD PERMIT NO. Z C2_ 3
LEGAL STATE ENCROACHMENT,
DESCRIPTION LOT N0. 1� PERMIT NO.
BLOCKTRACT Jl INDUSTRIAL. �- _
WASTE APPROVAL
SIZE OF LOT62/u / R1d NOW ON LOTS- CHARGES
USE OF
BUILDINGSVS Qi C�e[iPc[.CTP CONNEC ON CHARGE FEE
NO.. DESCRIPTION OF WORR FEE �� /
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE-4z� — - -
PUBLICSEWER Q $ 3.50 3 U RECEIPT N0: TE' I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
ALT E TO HOUSE SE1.00
ALTI__ I ER OR REPAIR EXISTING
=NO;_ DATE BYTING \+ `
SEWER OR DISPOSAL SYSTEM 1.00 Q U
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA
SEPTIC TANKEEPAE
PITS AND/OR,DRAi FIELD T OR 2.00 STATION 731-3 DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFER��yyCE,
-UPPER /y(� W Ole LOWER
TYPEOF CONNECTION LENGTH FROM
OWNERS PERMIT /
Y. ' CURB !/P.L. --M.L.TO P.L.
. ; I I OO
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
COAPPROVALS INSPECTOR'S SIGNATURE DATE
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER.
,,ggam�
SIGNED THIS.._I.F.....DAY OF./=La __.___.______19! -3 NEW HOUSE SEWER
OWNER OR a CONNECT ADDITIONAL
OWNERS AGENT t BUILDING OR WORK
ADDRESS. 70y �,_. .�e SEPTIC TANK,SEEP.PIT(S)
s........... . .. ___....._........__....._. AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES•AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSALSYSTEM
1 HEREBY CERTIFY THAT T AM 'PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDE4AL0?PERTY. BACKFILL SEPTIC TANKSSEEP.PIT(S)[ .CESSPOOLS E]SIGNATURE �/ JOFPERMITTEE` _ _..�. _ -..-._. ..____..
TOA642D 603 /
a ' WORKERS'COMPENSATION DECLARATION
I her*.off irm. thof I have a certificate,of consent to self
jniure,�or.-a Bert ficate of Workers'Compensation Insuronc% or 76A642D
CE SW(REV..Blt)1I
,.o lie-y i'e' copy.thereof(Sec: 3800, Lob C.). APPLICATION FOR �E��0T
Policy No.; Company - ®s ®�:1 a'66f1v!`I�
❑ Certified eop�is hereby furnished. SEWER o SEWAGE' DISPOSAL
❑ Certified copy is filed with the county building Inspection COUNTY OF LO.S.ANGELES BUILDING AND SAFETY
department. 4
Date_.Applicant.Applicant FOR.APPLICAIINT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS' LDID
rr7 j STATION DEPTH
COMPENSAT.IOIV INSURANCE Lt V }r'r' IL(:This Section need not be.completed if the work involved by the MANHOLE REFERENCE UPPER
LOWER
permit is for one hundred dollars($100).or'less.) TYPE OF CONNECTION LENGTH'FROM
I certify that. in. the performance of .the work for.which this ,, .0, Y. CURB P.L. M.L.70 P.L.
permit is.issued,:I shall not employ any person to any manner
so as to..become subject to the Workers"Compensation Laws. OWNER r CO.IMP;NO'. . IOB'NO.
MAIL ' TRUNK PERMIT NO. ROAD PERMIT.NO.
06. LJ V
Dote Applicant MAIL s t
NOTICE TO 4PPLICi4NT: If, offer makingthis Certificate Of �3 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
CITY ��,A r f,-. TEL:NO:
Exemption, you should become subject to the Workers LEGA[
Compensation provisions of the Labor code, you inUSf forthwith DESCRIPTION LOT NO. HWY.ORST,WIDENING
comply_with.'such provisions, or this permit shall be deemed
revoked. 1 BLOCK. TRACT STATE.ENCROACHMENT
LICENSED CONTRACTORS DECLARATION. No..OF BLDGS. PERMIT NO.
' _ :
I hereby affirm that I am licensed.under provisions of Chapter SIZE OF LOTNOW ON LOT
USE OF
9.(commencing with Section 7000) of,Div)'sion. 3 of the. B.usi= BUILDINGS CHARGES
n.ess and Professions Code; and my license is in full force and
effect.. CONTRACTOR 4 CONNECTION CHARGE,FEE
License Number LIc.,Glass AMRE95 REIMBURSEMENTfEE O
Contractor 'Date. DISTRICT NO;- GROUP MAP PROCESSED By U
CITY TEL.NO. BK PG
EJ STATE CC. / j]L 11/
-I.am exempt under-Sem of'the L.A.:Co;. i LICENSE.NO, CL'A55
NO DESCRIPTION OF WORK FEE
Plumbing Code anal.%or Sec. of the FINAL
LU
HOUSE SEWER CONNECTING tO DATE i < -�'�- •- VALIDATION IL
B. &P. Code for the following reason PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR 'FINAL �^ g
_ PITS AND�!OR.�DRAINFIELD
Date rDDREgS
OUSE SEWER.CONNE��TTIING TO BY
IVATE'QISPOSAL.:SYSTEM•
Signature NNECT ADDITIONAL BLDG,OR
OWNER-BUILDER DECLARATION ORK TO HOUSE SEWER.
VERFLOW SEEPAGE,PIT,DRAINFIELD 4
I hereby affirm..t.hot I am exempt from the Contractor's.License TN.,CESSPOOL,DRYWELL,MANHOLE. '
Law.for the following reason (Secton 7031.b, Busness and Pro.- LTER,REPAIR OR ABANDON HOUSE
fessian9 Code'): WER OR D.I5POSAL SYSTEM "
01,
I,.:as owner,of the property;or my employees with wages as
fhe'ir.sole compensation,will do the work-and the structure
is not intended or offered for:sale (Section 7084, Business PermitS 331 21.511
d'Professions Code). WNIER'.SlMl,os owner of the pcoperty;am exclusively contra.ctirtgwith 10RIZAT,ION1 T.O6AL PEE ITF
.IICenSed COI'1TractarS to COnStrUCf the pTalett (Section 7044; T THIS.DATE,A COJVTRACT 1NITH THE.HEREIN'NAMED CONTRACTOR TOTOTAL .2- t of
Business and Professions Code). T THE ABOVE DESCRIBED'EXISTINGDWELUNG•TO THE PUBLIC:SEWER,
'CONSTRUCTION TENDING AGENCY CK 2'1.50:
I hereby offitm that there is a construction lending agency THIS - DAY.OF9 ,.for the performance .of the work 'for which this permit is R CHANGE .1111
AGENT -
issued (See.'3097, Civ.:C.)
Lenders Name C000-00131.
lender`s Address
I certify that I have read .this application and state that the -6.784 1 AMU°o N. '
above information is correct. I agree to comply with all County
ordinances and.State laws regulating.. Plumbing: and :Sewers,
and her autF.iori rep sentatives. of this County toenter
U t ove-m tiq roperty for Inspection pu oses.
lo lure of Permitt . Date SEE REVERSE FDR EXPLANATORY LANGUAGE
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