HomeMy Public PortalAbout6016 PRIMROSE AVE_Sewer__ A1' R'I{l�RS'COiy1P1115'A'f IO:N llL'CZF\RATION 76/1842.D
-41.�" , APPLICATION F �R PERMIT
L CE 8Q8'I2-80)
r
I hgeh. ,affirm that. ? h''evp's certificate of:consent.to.Self ��,���-SEWAGE DISPOSAL
.ni'a certificate-w Workers'Colttpeasat'ion.Insurance,or
a cett{fted copy thereof(See.38.00,Lab. COUNTY OF LOS ANGELES BUILDING AND SAFETY
Policy NeIVM=851mpan y— zeiilfllll
Certified copy is hereby furnished,
APPLICANT TO FILL IN CONNECTION DATA
s UILDIN•$Ci STATION DEPTH.
' . .
.Certified copy is filed with the county •ADDHES
, building.inspection 6016 Pri=seUPPER
department., MANHOLE REFERENCE
LOCALITY LOWER
Date 4-7R—RF ApplicaniOldl'11 I�1 YIR- p1}](} NEAREST Ut��— TYp_@ OF CONNECTION LCN&T.14 FgOM'
CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS_- Y. CURP P.L. MA-1. TO P,L..
COMPENSATION INS'URANC'E P.C. NO.
OWNER ROn Owen CO. iMP. NO.. .106 NO.
MAIL D.
(this Section need not be completed if the Work involved Anon . Er 55'51 N. Hal.ifaX Rd.. T.RLINIG PERMIT N.O.. ROAD PERMIT'NO.
by the permit is for one hundred dollars ($100) .or less.)
AP PIDAVIT WAIVER 6'9SEMGNT RE.C,ORD.INSTR'.NO. DATE U
C�1TY T.E.L. IVO.__ —
I certify that in; the•:peeforfnauce' a!( the work for Which.this LEGAL - O
arra t is issued., I shall not employ any person in any manner DESC.A.IPTroN. LOT NO,
p � }" Hwy. OR'Sti". WIDENING
so as to become subject to the Workers'Compensation Laws:
BLOCK TRACT STATE ENCROAC MENT II,i
Date Applicant. NO.. OF"BLDGS. PERMIT NO.
'.
NMTO APPLICANT- If; after making:this Certificate of SIZE OF LOT NOW ON LOT t -
r~
Exemption., you :sho.uid become subject to the Workers' USE OF
ISUILDI.NGS CHARGES
Compensationprovisions of the Labor Coda, you must forth-
with comply with such, prgv1Si6n5 .or this permit shall b.eC'ONYRACTOR OWen .BMS. plumbing. , .Inc.: CONNMCTION CHARGE REE
domed revoked..
LICENSED CONTRACTORS DECL,ARATIO•Ny ADDRESS
4.265 N.. Baldwin Ave. RE:IM'H+U R.SEM EN7 FEE
'1 herob.y affirm •that 1 am.licensed.tind�er'provislon�s�o�f hapter •DICITRICT.NO... GROUP •MA,C (P.7C...A .19Y9 (commencing with Section 7000)of Division 3.of.the Busi- CITY EEL Mbnte TEL. No-443,-0078, BK PQ
ness and Professions Code, and my license is in full force and 16TATZ LIC.. •��
LI.CE.NSM'NO. 231 741. CLASS C36_'-20
effect. NO.. DESCRIPTION OF WOfiK FV E'
Na;,.sE SEWCR CONNEtSING:TO FltwlA� VALI:DAT ON..
License Nu.Mber -231 74'1 Lie.Class C3Fj=9.0 PUo1.1e 5%.%ER DATE -#G f
_ L'EPTIC.YPITS ANDJOR UANK,SREG .GAINVIELD
PAS PIT OR
C !
ontraetorOWen B2 OS. Pl} to 4-2.8—H6 13Y A. '
HOU 9E SEWER CONN GOTINq•TD '
O PR:iMATE DISPOSAL.SYST Fi M. DY
1 a.m exempt'from the licensing reyuireplents'as i.am'a
CONN EG:T ADDITIONAL OLDDG..DR'
licensed architect or 'a registered professional engineer w.Drt.K TO HDuse SEWER
acting in .my professional 'capac'i'ty (Section 7051., Bus. OV E'R FLOW SE6PA'.GE PIT.DRAINF1ELD
mess and professions Code) E,1Z.TN.;CES60004,DRrwaLL.,gnANNoI e.
ALTER,RRPAIR'OR AB'AN'DON HOUSE
SEWER OR'DISPOSAL VrS7EM
^
Lie,or Reg,No. Date
�>_55]
.
ai
HOME OWNI R-BUI.LD:ER'DECLARATION
Permit # QQOQ1
1 hereby affirm that. I am exempt from the Contractor's OWNER.S
8 0
License Law for tate following.reason (Section 703.1.5, Busi: AUTHORiZATiON TaTAL:FEE {. o o 27.50
negs and Profgssions.Cone), 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
.
'YRACTO.R TO CONNE6VcT'Tt1'G ABOVE'D'6 SCRIO HD g%ISTING DwRLLINO Q Q C 2'� 0
I, as owner of the property, .Will do the work and'the TO THE PUBLIC SEER.
structure. IS not intended or offered for sale (Selsdon SIGNED THIS- DA.Y OF 19 ���.�—86
7044,`Business and Professions.C`ode). aWNOR OR
OWNERS AGENT -
CONSTRUCTION LENDING AGENCY A.DDRL''SS.
I hereby affirm that there IS .a construction lending.ugency
for the performance of the work fbr Which this permit is
issued(Sec.$097,Civ.C.). �
Lender's Name
Len.lieOs P.d:dress
I certify that I Have read this application and state that the
above information is correct.I ggree to curnply with.all County
ordl rlues, and State, laws re, ul.athig Plum.bin.g anis. Sewers,
8n hereb . a htsrire r re. tines of this County Io enter.
ort th.e "fttenNo. d erty for inspection p'urpos,s.
SEiv RZVERSE FOR GXPI.ANATORY LANGUAGE.
ignature Of Ptrutitfit Date
V
S 5 C-663 i2.5d G APPLICATION FOR PERMIT
&E•6
DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING y
WM. J. FOX, COUNTY ENGINEER ADDRESS _,�'__
CASSATT D. GRIFFIN,SUP'T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST. ! 4 __
LEGAL TINO.
DESCRIPON LOT NO `-` -
OWNER
BLOCK. TRACT r `MAIL
----`-- — ADDRESS
N0,OF BLDGS,
517.E OF LOT �_ 'OW ON LOT —CITY Y TEL.N0,�4..,•>. ,.,i �' _
USE OF
BllfLDINCS DISTRICT NO. GROUP MAP
y.CONTRACTOR1 - I BK PG -
` � p F✓ I{
CONNECTION DATA �v —
•/I
CITY- x:Eo TEL. N0. STATION
DEPTH
Y yFd y' _ t EI-STATE MAi ^'FERENCE
-REGISTRATINU. I
ZL_ � O COUNTY UrPcR _ LO'NER
7 TYPE OF CONINECT,N LENGTH FROM
No, DESCRIPTION OF WORK" FEE Y� CURB Y.L. M.L.7o P.L_
HOUSE SEWER CONNECTING.TO
PUBLICSEWER__ - �_ $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
�i CONNECT ADDITIONAL BLDG. OR
TO HOUSE SEWER 1.00 CO, )S1 P. N0: JOB. NO.
4`JOiTK �
ALTER OR REPAIR FXI iN6
SIM ER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PcRM IT N0.
GI.iCONNE'l PND ABANDON SEE/ER STATE ENCROACHMENT
_ AND<OR D! 'OS,AL cYSi EM. 1.00 pEtZ hi l_T NO.
c P1I C TANK, SEEPAG. PIT OR�— -
Pm AND/OR DRAINF L. 6 2.90 ��— ,NDUS'TRIA'L
T --I' WASTE APPROVAL
E SOL DRiWELL
S IAL CONN IONS ON-1Y 2.00
CHARGES
I�PEI3MIT — -- CONNECTION CHARGE FEF_
OWNER'S
DO
— SSSS_
AUTHORIZATION TOTAL FEE j _. RFIMBURSERIENT FEE
I HAbE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- �+�yeb�•t176Y DATE INSPECTOR'S iOR'S 3I:NATURE
TRACTOR TO CONNECT THE ABOVE DESC ED Exi5StNG DMELLING APPROVALS 11AL TE C T .._.
TO THE PUBLIC SEWER "-
SIGNED T-115 � —DAY OF—
OWNER
F '� NEW HOUSE SEWER
OWNER. OR :ji ,+,„ `.� - J` CONNECT ADDITIONAL .
OWNERS A, ENT g.' I ��.j � �L�„.y �"-�-•1� le'.._.:' BUILDING `�---
ADOfIF SEPTIC TANK.,SEP, PIT($)
ANO/OR DRAiNF'I_LD�
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL O DRYWELL E]
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL .COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEVIER OR
PLUMBING- AND SEVERS. _SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/011DISCONNECT PLUG AND_
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER _
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ..
DES4,RIBED RESIDfINNAL PROPER T' ;,x BACICFILL SEPTIC F TAN�C5l] - -
� � a� V
} / pie, SEEP.PIT S) ® CESSPOOLS
PAV 4 1 ._�I `. � a tal ( _ _Q_
OF PERMITTEE
WILLIAM J. FOX,CC)Li 44Y ENGINEER � VAI.ID,ATION
A 2 '
BY BY
DEPUTY DEPUTY
BY BY
0 DEPUTY DEPUTY