HomeMy Public PortalAbout5806-5808 PRIMROSE AVE_Sewer__ APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County :Engineer
County of Los Angeles BUILDING
ADDRESS
JOHN r A. I_AIAF3IL, COUNTYENGINEER - - - -- �- ----- ------
CASSA'FT L?. GRIFFIN, SUrruE'BUlc.urruG r LOCALITY _----
NEAREST
FOR APPLICANT TO FILL IN CROSSATw i �- --
LEGAL - Z! � —.—_—.
DESCRIPTION LC'i N0._— > J UIYNEft �, � .4 d i�
--- --- --
BLOCK TRACT ' MAIL
-------------- ,, u — ADDRESS
NO OF BLDGS.
St_tT OF L07 NOiV ON 10_7— CITY _ x (.. TEL. NO, r _j
USE( I i � —
DISTRICT NO, GROUP MAP
GIC Pr
CONTRACTOR 4.
Ix
ADDRFS � + —. � CONNECTIONDATA
STATION
CITY
_: f____----TEL_NOe ._".__. .—_
REE[STRATdON NO, Y ... STATECOUNTY LOWER
No. ! DESCRIPTION OF WORK FEE
—___s --- -_.-- --_--- .-_-- .—_— TYPE,OF CONNECTION. LENGTH FROM
gJ I
HOUSE SEWER CONNECTING TO I Y. CURB�_—. P L. M L. TO F L
I 'SL!C SEt'� R (w S ay3i7`r" 1 — ----— . _--- — —
SEPTIC TANK SEEPAGE PIT OR j
PITS AND/On DRAINFIFLD rl $,.00 _----
O/ERFLOW SEEPAGE PIT DRAINFIELD P C. NO.
EXfEV.,CESSPOOL,DRY ELL,MANHOLE z $2. _—T I CO, 1hiP. NO. JOP N0.
HOUSESEWER CONNECTING TO '
_ PRIVATE:DISPOSAL SYSTEM cr: s 1.00 .PO
i TRUNK PERMIT NRD PERNO
.J CONNECT ADDITIONAL BLDG OR ._._ .
- __--OA—_..._MIT ...- --
i I I STATE ENCROA�..r.teiE;e'i'
WORK TO MOUSE SEWER (a
$;.CD ERA IT NO.
r ALTER,REPAIR OR ABANDON HOUSE ! INDUSTRIAL
SEWER OR DISPOSAL SYSTEM kr' y.1.00 � I -_ WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT
AUTHORIZATION Tv°�AL E — � 0 REIMBURSEMENT FEE'
I HAVE AT THIS -DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS _j CATS �INSPE.CTOR aSs:G[dATUF.E
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - r
TO THE PU3LIC S'EWF.R. NEW HOUSE SEWER
SIGNED T}iIS— DAY OF 19T CONNECT ADDITIONAL
- - -�= -- -- -- ---
-
OWNER O`i
BUILDING OR WORK
OWNERS AGENx�A%,�d ./�aL` �,✓�(F.r ,+^i'';�..:.�,. --- -. -- --------- ----
n SEPTIC TANK.SEEP,PIT(S)
ADDRESS.— AND/OR DR A.iNFIP.LD
I HEREBY A. KN :LEDGE THAT 1
HAVE READ THIS APPLICATION --- _-----`_---
CESSPOOL DRYWELL i
AND SCAT.. THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY" --- `-- -..L—_��___ __._. _ .—"._.__
WITH LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR,SEWER OR
"LUNB N AND SEWERS SEAArAGE DiSP05AL SYSTEM
i R R r CERTIFY 4 AN ROPERLY REG S3'RFD AND/OR DISC--- —
f AJ'E OF ABANDON
N H PLUGAND
LICENSED AS T P" LOS ANGELES CCI' Y AND S?
_ABgNDUN HOUSE SEWER ! r
CALIFORNIA O; -HAT r AN! THE� Lc=AL rNER OF TFi'r-y+`'ABOVE - -- -_._
DESCRIBED Rk: DLNTr,;rr'PRC:I.PERTY. , ,i BACKFILL SEP NO TgNKS❑ '-
,�— - SEEP.Par ,S; L7 CESSPOOLS.(-IGIMATURE
j
OF PERMITTEa.,
i
IOHN A. L°AMBIE, Cc NTY ENGINEER ,,4ALIDA TION„.: ROSERT A.WOOD,CHIEF PLEIG, INSPLCrCIR
CK. c q j cnsw
' - ,. z �. -... 'ice 44 ..,.d �✓”; _
r4 ' WORKERS'COMPENSATION DECLARATION
I hereby.affirm that I have, a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, or 76Ae42D
a certified copy thereof (Sec.'3800, Lab C. CEBDB(REV.8/61) APPLICATION FOR PERMIT
Policy No. ' Company OOs
❑ 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' BUILDING �f Q 6�. STATION �`j r / DEPTH
COMPENSATION INSURANCE ADDRESS 1 ,6 r
(This section need not be completed if the work involved by the oCAury 1 64 r MANHOLE REFERENCE UPPER
P a
permit is for one hundred dollars ($100)or less.)
NEAREST TYPE OF CONNECTION LENGTH FROM.
I certify that in the performance of the work f hich this cRoss sr. Y. CURB P.' M.L.To P.I.
permit is issued, I shall not employ any person i an manner
so as to become subject to the W ker'Com en ati Laws. P.C.NO
OWNER CO.IMP.NO. �._ JOB NO.
Date"`�.� 9 MAIL C), TRUNK PERMIT NO. ROAD PERMIT NO.
—A :l Applicant ADDRESS
NOTICE TO APPLICANT: If, after making CITY TEL.N
this Certificate of AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NQ DATE
f+ E'„
Exemption, you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. HWY,OR ST.WIDENING
comply with such provisions or this permit shall be deemed
revoked. BLOCK TRACT PSTATE ERMIT NO.OACHMENT ` /13 '
LICENSED CONTRACTORS DECLARATION NO.of LOT (Gl 7
SIZE OF LOT �` NOW ON LOT �-
Ihereby affirm that I am licensed under provisions of Chapter USE
of
9 (commencing with Section 7000) of Division 3 of the Busi- USE DINGS CHARGES
ness and Professions Code, and my license is in full force and � �
effect. CONTRACTOR lO{oc�Ju ell" CONNECTION CHARGE FEE
d
License Number LIC.Class ADDRESS REIMBURSEMENT FEE O
Contractor Date '[�� DISTRICT NO GROUP MAP ESSED BY V
CITY TEL.NO. BK PG Z
El STATE / 6 ,I am exempt under Sec. of the L.A.Co. LICENSE CLASS
L No LIC. Q
No. DESCRIPTION OF WORK FEE `` V
Plumbing Code and/or Sec.---of the FINAL a
VALIDATION
HOUSE SEWER CONNECTING TO - DATE / -�
B. & P. Code for the following reason PUBLIC SEWER / ' H
.SEPTIC TANK,SEEPAGE PIT OR FINAL y
PITS AND/OR DRAINFIELD /
Date — HOUSE SEWER CONNECTING TO BY
PRIVATE DISPOSAL SYSTEM J'
Signature CONNECT ADDITIONAL BLDG.OR
OWNER-BUILDER DECLARATION ez,WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT,DRAINFIELD v
I hereby affirm that I am exempt from the Contractor's License EXTN,CESSPOOL,DRYWELL,MANHOLE
Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE
e fess!ons Code): SEWER OR DISPOSAL SYSTEM
L�9 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 $ r)
❑ I,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE - t �< 7. A
I LZlicensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED C NTR CTOR TO
Business and Professions Cade). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIf SEWER. fr` V a d 10
CONSTRUCTION LENDING AGENCY f
I hereby affirm that there is a construction lending agency SIGNED T
HIS _DAY F C 19 TH , E 49, %`(1
for the performance of the work for which this permit is OWNER O .
OWNERS ..X
issued (Sec. 3097, Civ, C.). - t
ADDRESS �' - f
Lender's Name
Lender's Address
I certify that I have read this ap lication and state that the
above information is correct. I a ree to comply with all County
ordinances and State laws re ulotir Plumbing and Sewers,
and hereby ou Drize repres nt tiv of this County to enter
Upon t -mention inspection purpo�sse'Js,
tg ature o Permit a Date SEE REVERSE FOR EXPLANATORY LANGUAGE