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Home My Public Portal About5337 PAL MAL AVE_Sewer__ DEPARTbffiNT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEERI BUILDING --.-� .� _ ADDRESS _..J L BUILDING3FORAPPLICANT T F L.)N LOCALITYADDRESS NEAREST /[•' CROSS ST. G �GLOCALITY DISTRICTN0. SERIAL NO. PERMIT NO..NEARESTfl _ A ��//`J S CROSS ST. RECEIVED ILY - Ready far Inspection E ISSUOWNER MAIL ADORESS i - USE ZONE OCCUPANCY P BK PB CITY _ TELAO. CONTRACTOR V _ - CO.IMP.N0. ADDRESS �' FQ_� Lam- �L..61{' JOB.NO. J CITY n F) ('n, TELAO. FC`�`R_'j TRUNK PERMIT NO. TATE REGISTRATION N0. /� 5` ❑ COUNTY ROAD PERMIT NO. LEGAL STATE ENCROACHMENT DESCRIPTION LOT NO �l 4.� PERMIT NO. BLOCK _ TRACT 11 2 9 o INDUSTRIAL WASTE APPROVAL SIZE OF LOT ? x 7 Q O NO.OF BLDGS. 1 NOW ON LOT CHARGES USE OF ,/� _ _ b BUILDINGS lf� �� - �i�j� CONNECTION CHARGE F" NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE PUBLIC SEWER 0 S 3.50 D RECEIPT NO. TE I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO HOUSE SEWER 1.00 Oli ALTER OR REPAIR EXISTING NO. I DATE I BY SEWER-OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTICTANK,SEEPAGEPIT OR - --- PITSAND/OR DRAINFIELD 2.00 STATION DEPTH �SPSESkNFCONDITIONS L—DRYWELL ONLY 2.00 /L/O / �-MANHOLE REFERENCE 7 �i UPPERD �� TYPE OF CONNECTION LENGTH FROM OWNERS PERMIT f I 00 G std M.L.TO P.L. �D AUTHORIZATION TOTAL FEE �_ G 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE DWELLING TO THE UBLIC SEWER]`- SIGNED THIS_ 9 . .__DAY OF.... S EW HOUSE SEWER ' OWNER OR �' ` CONNECT ADDITIONAL :z9' yL u OWNERS /,)GEN • .L B ILDING OR WORK j - _- ,-�- -- -- SEPTIC TANK.SEEP.PIT(S) ADDRESS..� _ ----�--- ._._...... .....__._--_-------- __ AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 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 DISPOSAL SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN. ABANDON HOUSE SEWER ER OF THE ABOVE E$CRIBEO RESIDEN IAL PROPERTY. BACKFILL SEPTIC TANKS SEEP.PIT(S)EI CESSPOOLS SIGNATURE -�r/- - OFPERMITT �...._.. .._ _.._.. ._.._... NA642D 663 1/53 ! f WORKERS COMPENSATION DECLARATION D • 8 ( 80) CE APPLICATION FOR PERMIT {� CE 80 l J 1 hereby affirm that I have a certificate of coment to self SEWER-SEWAGE DISPOSAL insure or a certificate of Workers'Compensation Insurance,or e certified copy thereof(Sec 3800 Lab C) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No Company ri Certified copy is hereby furnished FOR APPLICANT TO FILL IN CONNECTION DATA ou'LDinO �32 Q� STATION DEPTH 13Certifiedcopy b filed with the county building Inspection woe:e/S /T uPr[R department LOCALITYG' MANHOLE wvu[ncE LOWER Date Applicant NEA:Ess TVP[ Or CONNECTION L[NOTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' Cw0///T V CURB P L M L To F L COMPENSATION INSURANCE J �r � u ' C NO OWNER �/ /V 'V CO IMP NO lOY MO (This section need not be completed tf the work mvoh)ed MAIL p ADDR6// a by the permit is for one hundred dollars (5100) Or less) TRUNK PERMIT NO ROAD PERMIT NO,C •PP,DAVIT w.n.w ...... ,M.Tw CITY (,� cr EL NO oZ,3 U 1 certify that to the performance of the work for which this LEGAL permit o Issued, I shall not employ any person In any manner DESCRIPTION LOT No HWY ON ST WIDE NG � so as to become subject to the Workers'Compensation 0 CLOCK TRACT STATE eNCROA HENT PERM IT No �Date//f—/T ADDIIcant No of ELoo• W NOTICE TO APPLICANT fter making this Certificate of nse or LOT 7 S7 nor on LOT N USE Or Exemption, you should oma subject to the Workers Euis.Dlno• c.wwoe• 2 Compensation provisions the Labor Code, you must forth With comply With such provisions or this permit shall be CONNECT N CHAROE Fee deemed revoked CONTRACTOR R EIM EU R/[MEMT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that 1 em licensed under provisions of Chapter I.Twie.Mo DRooP 9 (commencing with Section 7000)of Division 3 of the Bust CITY TEL No t/ - ness and Professtom Code and my license Is to full force and /ICUN CIL ,sc0 Q -3 !'IG affect No I No csAu NO DESCRIPTION OF WORK F[6 a.m.. Hou.• .EWER cis„N.cT,No TD FINAL VALIDATION License Number Lm Clan— DATE LClaPLIC..NO ..as.Oa PIT un Pe r a r ow Contractor Date P.T.ANDIOR OwuwnuD FINAL HWaP .P:aw .....eT.. TO EI. ❑ C..ATP DI.POPIIL/Y.TaM I em exempt from the register requirements u t em a .... To .........Leo ON licensed architect or a registered professional engineer .oRR To MOD.a.waw acting in my profmionel capacity (Section 7051, Bus ....PLOW..a FA.a NT o.AI..I.LO mesa and Profesnons Code) N.Y. C..000L DAY. .1 MANHOL. ..T.. waPuw 0.........eo.a UK. OR Ouro.wL.Y.T.. Lic or Reg No Date HOMEOWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit 5 d License Law for the following reason (Section 7031 S. Bust AUTHORIZATION TOTAL FEE LS nest d Professions Code) I NAVA AT Tat,. DAT/ w CONTRACT WITH TH.H.RaIN HAMCD CON- 2 1 Ll A W as owner of the property will do the work and the io THU�Uiilcii�illT Tata•Nov.D..cwlP.e lA,.T�NO D..LLIMD # • • • • 10 structure is not intended or offered for sale (Section atanco THIS owv OF o 7044, Busmen and Professions Code) oWN.R ow 2 - 1750 D.N.w.AD.. CONSTRUCTION LI'NDING AGENCY ADD...• 1 hereby affirm that there N a construction lending agency A • A 1 7 5 0 j for the performance of the work for which this permit is issued(Sea 3097,Civ C) 1 201 -81 Lender's Name Lender's Address 1 certify that I have read this application and slate that the above information Is correct 1 agree to comply with all County ordinances and State laws regulating Plumbing and Sewers and hereby authorize representatives of this County to enter upon the above mentioned properly f r idsp lion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE /1 Signature of Permittee Data