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Home My Public Portal About9095 OLIVE ST_Sewer__ 346:50 INSERTS 60 APPLICATION FOR PERMIT 78A842D SEWER SEWAGE_ DISPOSAL COUNTY OF LOS ANGELES DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION IIUDILDING ADRESS IOi-I1N'A. LP,MBIE, County Engineer WILLIAM A. MNSEN, Supt of Building LOCALITY { NEAREST FOR APPLICANT TO FILL. IN CROSS ST.— LEGAL T.LEGAL DESCRIPTION LOT NO. OWNER 9LOCK22 TRACT MAIL ADDRESS N0.OF BLDGS. SIZE OF LOT NOW ON LOV, CITY TEL. NO. USE OF DISTRICT NO. GROUP MAP PROCESSED BY BUILDINGS s I SK PG CONTRACTOR ` ADDRESS_J. CONNECTION DATA CITY / TEL.N0. i ,' STATION i' DEPTH MANHOLE REFERENCE REGISTRATION N0. ,J COUNTY - - LOWER Na. DESCRIPTION OF-WURK FEE HOUSE SEWER CONNECTING TO PUFLIC SEWER cy s_- w A - — —' TYPE OF CONNECTION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. :-CUT 5 P.L. M.L.TO P.L. ITS AND_/OR DRAI.NFIELD 0 $3.00 OVERFLOW SEEPAGE PiT,DRAINFIELD EXTN..CE5SPOOL.DRYW"ELL $2.00 Vf HOUSE SF vE.CONNEC"TING TO - P.G.NO. PRIVATE PO'AL SYSTEM @ $1.00. C'.O.IMP, NO. JOB NO. � CONNECT ADDITIONAL BLDG.OR I ." TRUNK PERMIT NO. ROAD PERMIT NO. - �—,i� yf WORD TO OUSE SEWER C�+..3f,9r1- .r U ALTER,RF FAIR OR ABANDON HOUSE ! STATE ENCROACHMENT t>•°. SEWER OR DISPOSAL SYSTEM (7 $1.00 I _ PERMIT NO. O iNDUSTRI;AL W z-1 ;•r WASTE APPROVAL c f s CHARGES OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE zy AUTHORIZATION I TOTAL FEE t' FEIMHURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WIT HEREdN NAMED CON- TRACTOR TO CONNECT THE ABOVE D CRIB E +STING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE T THE PHSEWC S[ — SIGNtI? THIS _.,.��...- Y OF 19 _NEW HOUSE SEWER" OWNER OR CONNECT ADDITIONAL OWNER:SAGENTi"- OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) ---- AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CQMPLY CESSPOOL EDDRYWELL.❑ _ . WITH ALL COJNTY ORDINANCES AND STATE LAWS REGULATING ALLTER,Rc.PAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL,SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND I LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND NATE OF LISCON N HOUSES AND CALIFORNIA OR THAT I AM WER iH ` LEGAL OW E. F ABOVE ---- - --r--® DESCRIBED RE'IDEN P DEE' EACKFILL SEPTIC TANKS ❑ SIGNATURE SEEP.PIT(S) IW CESSPOOLS +. OF PERMITTEE �7p "VALIDATION ROBERT A. WOOD 'CR. ,+ M.0. CASH SUPERVISING MECHANICAL ENGINEER WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation insurance, or %6AS42D o certified copy thereo (Sec. 38900, Lab C.) sz-000 DPW E AAI At APPLICATION FOR PERMIT Policy No..�l 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. Date `Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGr . COMPENSATION INSURANCE ADDRESS siATON DEPTH (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE 7 !". e 'UPP' permit is for one hundred dollars ($100) or less.) :r LOWER NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y cLieB; P L M L.TO P.L permit is issued, I Shall ncffimploy any person in any manner . so as to become subject-to thb'-Workers' Compensation Laws. P.0 No. OWNER !�MAIL CO.!MP.NO. JOB NO. ^_ Y �• ADDRESS T TRUNK PERMIT NO. ROAD PERMIT NO, Date Applicant this Certificate of AFFioavlT WAVER EASEMENT RECORD.INSTR NO DATE NOTICE TO APPLICANT: If, offer making CITY -..,fTEI NO.,r. me,, ' 7''4.`1` e Exemption, you should become subject to the Workers, _EGA{— -- Compensation provisions of the labor code, you must forthwith DEscRIPT;oN LOT NO.<' f HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK° / TRACT ! STATE ENCROACHMENT . LICENSED CONTRACTORS DECLARATION NOOF BLDGS PERMIT NO.NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter e 9 (commencing with Section 7000) of Division 3 of the Busi- &.0,r.,ln ; CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR k_ y kOL Or!"aC Int r,AR v GE FEE t License Number_ i ,LIC.Class g ADDRFSS s. w �. 4 REIMBURSEMENT FEE Y ":e -i `v '"/! DISTRICT NC. GROUP MAP PROCESSED BY z Contractors Date _w-.,- � CITY'„t ,. TEL,NO. d s ' ` BK PG ff''��I STATE UC. tt L_ E am exempt under Sec.------of_ the L.A.Co. IICENSE NO A3 CLASS Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL + � (i a- HOUSE SEWER CONNECTING TO DATE VALIDATION u) B. R P. Code for the following reason PUBLIC SEWER ;£ z SEPTIC TANK SEEPAGE PIT OR FINAL PITS AND/Oft DRAINFIELD __.-.----- Dat® HOUSE SEWER CONNECTING TO BY ^� PRIVATE DISPOSAL SYSTEM I hereby affirm OWNER-BUILDER CONNECT HOUSE BLDG.OR Signature DECLARATION WORK 70 HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD y pt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR AB NDON HOUSE fessions 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 and Professions Code) OWNER'S Permit $ 0-- ❑ I,as owner of api rty,am exclusively contracting with AUTHORIZATION TOTAL FEE k'. I:.s;.-.> licensed Lantra'tars construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business d(d +r fessi"Ins Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. G;ONSTROCTION 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 ADDRES ` Lender's Address I certify that I have read this application and state that the above inforrnation is correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, and hereby authorize �epresentatives of this County to enter an the above-mentioned property for inspection purposes.. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE