HomeMy Public PortalAbout9405 PENTLAND ST_Sewer__ i&E 563 12 04' APPLICATION ` FOR�PERMIT ` 5
d{BDMSION OF BUU.DING AND SAFETY' 'SEWER-SEWAGE DISPOSAL_
Deportment of County Engineer
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County of Coe Angel, - .a)
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SDESCRI PTION viLOT+NO'���}�./�',i�}._ • OWNER
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ADDRESS �^.. A /'• a n
V SIZE OF LOT J' !■.S/I' �.L;'�lA�-NOWOON LOTS , CITY TEL MOcq `
USE OF
Y
F BUILDINGS M K 4 �..�. DISTRICT NO GROUP ' YAP
_ f � Il _
I CONTRACTOR �� � �A T
ADDRESS , 7- " v CONNECTION DATA
CITY'? „TEL NO i�9 STATION DEPTH ('
'(,1{/''� --E- STATE MANHOLE REFERENCE d,,r
REGISTRATION NO FI ❑ COUNTY UPPER ,/' LOWER
TYPE.OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L�
HOUSE SEWER CONNECTING TO P f
PUBLIC SEWER (jD $ 350 I
HOUSE SEWER CONNECTING TO w.
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONA CO IMP
INO �JO NO
WORK TO HOUSE SEW L'lY'�"�'• 1 00 _
ALTER OR REPAIR EXISTING TRUNK PERMIT NO h f,ROAPERMIT NO
I SEWER OR DISPOSAL-SYSTEM 1 00
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
t} AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
+ TSEPTICVANK'SEEPAGE PIT OR
_JPITS !NO/OR DRAINFIELD 2 00 1 INDUSTRIAL Y
L
T'CESSPOOL- DRYWELL —— WASTE APPROVAL v
SPECIAL CONDITIONS ONLY 200 __ `r CHARGES
CONNECTION CHARGE FEE
p OWNERS PYHMi'1' Er17-
100 AUfTHORIZATION TOTAL'FEE- 11
REItl BURSEYENT+FEE
I' HAVE THIS GATE CONTRACTED WITH THE-HE NAMED CONAi c( APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING'DWELLING-
TO THE PUBLIC SEWER ' NEW HOUSE SEWER +
SIGNED THIS DAY OF 19-
CONNECT ADDITIONAL R�
OWNER OR r _ f • BUILDING OR WORK
OWNERS AGENT- J ��
ADDRESS t 1 c .M �w� A. f SEPTIC TANK SEEP PIT(S) y
AND/OR DRAINFIELD
[`HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELLl�b
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS
. SEWAGE DISPOSAL SYSTEM -
HEREBY CREQUIRED
;STH A BY I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND ,
LICENSED AS REOVIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
M +
CALIFORNIA OR THAT4IIrATHE LEGAL OWNER OF THE ABOVE _
4 DESCRIBED RESIDENTIAL PROPERTY I BACKFILL SEPTIC TANkS • •I
a p• ;.+, SEEP PIT(S) ❑ CESSPOOL
SIGNATURE • I `
'OFPE_RMITTEE
7
zW ILLIA nJ FOX ,COU NTt}'�ENGIN EER T VALIDATION n
'
BY
' ' 1l v�By 1 G+ sn{f ✓
DEPUTY dI DEPUTY
t
BY BY s R t ,..n •
r (JP DEPUTY f DEPUTY
WORKERS COMPENSATION DECLARATION
I hereby affirm that I hove a certificate of consent to self - SISI
incur or a certificate of Workers Compensation Insurance or 7�RD
f d y ere ' S,,.3 -' �- GEBDB,REV B/BI' AP LICATION FOR P IT
CE
❑ Ifled copy IS hereby furnished SEWER - SEWAGE DIS OSAL
Certified copy Is filed with the county building Inspection D COUNTY OF LOS ANGELES BUILDING AND SAFETY
art nl
Dot ppLcant7J���:///l�fCl/' FOR APPLICAN LL IN CONNECTION DATA
CERTIFICATE OF EXEMPTION FROM WORKERS
BUILDING
COMPENSATION INSURANCE ADDRESS STATION DEPTH
(This section need not be completed if the work Involved by the ,��REPERENCE uwER
permit is for one hundred dollars ($100)or less ) Loco'urY LOWER
I certify That in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FRM\CROSS ST Y CURB PL ML TOPL T
permit Is issued I shall not employ any person in any manner PC No1
so as to become subject to the Workers Compensation Laws OWNER CO IMP NO JOB NO 0
MALI
Data Applicant TRUNK PERMIT NO ROAD PERMIT NO
'SD�u
FFIDAVIT WAVER EASFMFM
NOTICE TO APPLICANT If after making this Certificate of CRY TEL NO -A RECORD INSTR PID DATE O
U
Exemption, you should become subject to the Workers LEGAL
DESw
Compensation provisions of the Labor code you must forthwith
DESCRIPTION LOT NO -
com with such provisions or this HWY OR ST WIDENING 1
comply p permit shall be deemed N
revoked BLCCK TRACT STATE ENCROACHMENT Z
LICENSED CONTRACTORS DECLARATION NO OF BOGS PERMIT NOSIZE OF LOT NOW ON LOT
I hereby affirm that I am licensed under provisions of Chapter I
9 (commencing with Section 7000) of Division 3 of the Businets and Professions Code and my license is in full force andeffe t RACTOR CCNNECTX] CHARGE FEE
L,cen e N bei �+ _CLIC CIO33�/ ss REIMBURSEMENT FEE
DISTRICT NO GROUP P PROCESSED BY
"❑ am mpt under Sec of the L A Cc UC //)) / Q BK —.�F NO UC 'B 3 D RI CONNBCF OO FEE ,1 r !/
Plumbing Code and/or Sec of the FINAL
H10USE SEWER CONNECTING TO DATE r VALIDATION
B 8 P Code for the following reason SEPTIPURC SEWER
SEPTIC TANK SEEPAGE PIT OR FINAL
PITS AND/OR ORAINfIELD r /
Dote HOUSE SEWER CONNFCTING TO BY
PRIVATE DI SYSTEM
Signature CONNECT ADDITIONAL BUDG OR ►
OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER
I hereby affirm that I am exempt from the Contractor s License OVERT FLOW roPA IE ITDRAINNFFIELD
Law for the following reason (Secton 7031 5 Bwsness and Pro- ALTER REPAIR OR ABANDON HOusE - -
fe3sions Code) SEWER OR DISPOSAL SYSTEM
❑ 1 as owner of the property or my elnployees with wages as Jr 1 9 S A -
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 $ 6, # • • • • 1 0
AUTHORIZATION '
I as ownerofthe property am exclusively contracting with TOTAL FEE er O -,- 2l.-50
licensed contractors to Can51NCt f{le protect (Section 7044 I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO C
Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER i•(• 2 1 5 0 F
CONSTRUCTION LENDING AGENCY •
I hereby affirm that there is a construction tending agency SIGNED THIS DAY OF 19_ , 09 1 4'-83
for the performance of the work for which this permit Is OWNER OR
issued (Sec 3097 CIV C ) OWNERS AGENT -
ADDRESS
Lander sNome -
Lender s Address
I certify that I have read this Opplraation and state that the
above information is correct I agree to comply with all County ,
ordinances and State taws regulating Plumbing and Sewers '
nd hereby author'ze represe tobves of this County to enter
u bove-mentioned arty for repection purposes
Signory of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE
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