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Home My Public Portal About5438 PAL MAL AVE_Sewer__ TewuxD DEBGB" APPLICATION FOR PERMI COUNTY OF LOS ANGELES SkWER-SEWAGE DISPOSAL DEPARTNh:NT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION SulLDyra ]OHN A LAMHIE Cavn1� EvpmEEr ADORE e WILLIAM A JENSEN SvP f vl 6vildmq LOCAL TY NEAREST PPLICANT TO MIT IN CROS` ST LE [DT-=1LION NO 4E s WN6R MAIL CT O ADDRES9 NO OF BLDGS NOW ON LOT CITY L NO DISTRICT NO GROUP MAP PROCESSED BY �,� DK PG �/J CONTRACTOR I I (/�� ADDRESS /�—o CO CTfON DATA CITY TEL No a STATION DEPTH UPPER REGISTRATION REGISTRATION NO �(, COUNTY MANHOLE REFERENCE LOWER No DESCRIPTION OF WORK E[[ TYPE OF CONNECTION LENGTH FROM HOUR[SEWER CONNECTING TO Y CUR[ PL 'L TOPIL PUBLIC SEWER Y {BOO 8[PTICTANK S[EPAGEPIT OR op Nmoo Jv PITS A"DAND/OntDRAI"FICLO [1000 CO IMP NO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM 0 S]OO CONNECT ADDITIONAL SLOG OR /'{.yq AFFIDAVIT R.bu [gU[Ili RECORD INSTR NO DAT[ WORK TO HOUSE SEWER 0 S]OO LJ IJ OVERFLOW SEEPAGE PIT DRAINFIELO E1 M CESSPOOL ORYWELL MANHOLE Q 6500 ALTER REPAIR OR ASANDOX HOUSE HWY ORST WIDENING SEWER OR DISPOSAL SYSTEM Q {900 STATE ENCROACHMENT PERMIT No INDUSTRIAL WAST[APP OVwL �� N oaYL[{ C 6S OTY [S PERMIT f 2 00i AUTHORIZATION TOTAL FEE () N" IOn NA OE [[ I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FE TRACTOR TO CONNECT THE ABOVE DESCRIBED BEISTIMO DWELLING APPR01AL8 TO THE PUBLIC 99WAR DATE INSPECTOR S SIGNATURE SIGNED THIS DAX OF 19 OWNER ORNEW HOUSE SEWER OWNERS AG8 rt COXMER ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK SEE} PIT(S) 1 HERESY ACFN WLEOOH THAT I AV[ RHAO TN A LI ATION AND/OR GRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AOR[8 TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AMO/OR ALTER REPAIR SEWEROR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM 1 CALIFORNIA OR THAT I AM THE LEGAL OWNER 01 O IM[NO TO pISCONNECT PLUG AND R RESIDE IN THE ABOVE 4LRISE IIS ENTIAL P PREY DI ON ECT PL SEWER SIGNATURE OF P[RMITT[[ BACKFILL SEPTIC TANKS ❑ SEEP PIT(S) ❑ CESSPOOLS ATIOIJ,--) ROBERT A WOOD CK M o CASH SUPERVISING MECHANICAL ENGINEER LAC04 1 6 5FJ X11 1 0 D 5.00- v ' WORKERS'COMPENSATION DECLARATION I hereby affirrp tF&t 1 hove ct xerpficat9 of compel m self ' imwe Wit ci"rficbte of W&kem'Compe;t;wton Insurprise, fir nue"E' °"""'�`°p' b°r°°''Ssc `°°" "°°°'°PwN" Policy No Company APPLICATION FOR PERMIT ❑ certified copy is hereby fumishHd ' 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' 1tlrRwtc COMPENSATION INSURANCE ADDRESS STATION OflTli (This section need not be completed if the work involved by the permit is for one hundred dollars($100)or less ) tOcxm AtAHHOUI s� UPP[R I certify that in the performance of the work for which this NEAREST EARE 6T n'Na00"t�f101' LENGTH FROM permit Is issued I shall not employ any person in any manner y CIAEe P e AIL TOP L so as to become subject to the Workers Compensation laws OWNER Co W No ioe No Date Applicont AoAAAnss Z Q Taira PERAtrt NO Roro RDuvl NO NOTICE TO APPLICANT If after making this Certificate of �, ( IW ANCAVIT wAMR EASEA1ENt iaCOla Riots NO oArt Exemption, you should become subject to the Workers' LEGAI Compensation provisions of the Labor code,you must forthwith ocYa i for rao comply with such provisions or this permit shall be deemed lour GR ST WIDEN04 revoked eaO( TRACT PATE EN4GAOIWM LICENSED CONTRACTORS DECLARATION OF ALOGS 1ERANT NO 1 hers affirm that I am licensed under slaaeor OCH NOW ON Eat by provisions of Chapter USE a 9 is and ro with Section d my of Divlicense, i 3 of the Band BUILDINGS CHA*1 nets and Professions Coda, and my license is in full force and effect CONTRACTOR CONNECTION CHARGE FEE License Number Lic Closs ADDRESS HI FEE Contractor DoteCITY m NoDaIRKT No GN7UI Aw sy SATE LIC ,LZ A V ❑ I am exempt under Sec of the L A Co UCENSE NO CLASS .v3 ' Plumbing Code and/or Sec of the NO DE5CRiFn0N OF WORK FEE HHNw HOUSE sw[R CONNECTING TO VALI ATION B & P Code for the following reason POaIC NwER SEEPAGE mow DATE ��I Z Date PRS AFDr By IEDute Seurat CONERe*TO A $gnature UUNI ECT AC09ONAL SM OR ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Can troctor's Lncame Orth AIANIIDIE 10 Low for the following reason (Seclon 7001 S, Buisness and Pro- N R OFNR p ti0lFie tensions Code) sewed ON OtSPOSN SYSTEM ACCT.0 ❑ I,as owner,of the property,or my employees with wages a their sole compensation, will do the work and the structure 3307 27.00 is not intended or, offered for sale (Section 7041, Business 1 ITEtIS and Professions Code) OWNER'S Permit $ ❑ I os owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE In TOTAL 27.00 licensed contractors to construct the project (Section 70" 1 HAVE AT IRIS DATE A CONTRACT WITH M HEWN NAAIED CONIRACrdR To /.Et��y Business and Professions Code) CONNECT THE ABOW oU"M EXISTING DWELLING To THE PUBUC SEWER CK� 27.0 CONSTRUCTION LENDING AGENCY , C .00 I hereby affirm that there u a construction lending agency S*N1OTKIS DAYOF lv_ for the performance of the work far which this permit is OWNIFR OR Issued (Sec 3097, Civ C ) OWNERS AGENT Lenders Name ADDRESS- OODD"0001 $721/91 Lenders Address 250.3 1 fM $148 1 certify that 1 have rood this application and stole that the above Information is correct I agree to comply with all County ordinances and Sate lows regulating Plumbing and Sewers, and herebyy authorize representatives of this County to enter upon tis b �rrmentioypd property fo inspection purppo/s�r ASA Signature o erns M Date 1T / 1111 jEEVEM FW 11XPRAPIAT011Y LAM WA04