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Home My Public Portal About9121 PRIMROSE AVE_Sewer__ DEPAKTBEENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION r_. COUNTY• OF LOS ANGELES euLD1Nc WILLIAM J. FOX. COUNTY ENQINEER I ADDRESS ORh APPLI NTT FILL LOCALITYBUILD �� 1 ADDRESS / ,/ CROSS ST. �. � V 04 �1�C.18 �� j�i LOCALITY /.� �%//.off `�o '( ! DISTRICT N0. p SERIAL N0. ,� PERMIT N0. NEAREST 'S A� '�65/ 5 d /3 6-s CROSS ST. , {+��'{,j/J � �CEIEBY Ready for for Inapeotlon DATE ISSUED OWNEROC YOQ MAIL ADDRESS oo� �►��jsJ USE ZONE OCCUPANCY K MAP CITY / /O ~ TEL.NO. L�/ .J /D r /.A CONTRACTOR/ CO.IMP.N0. / � C ADDRESS JOB NO. CITY TEL.NO. TRUNK PERMIT NO. STATE REGISTRATION NO. ® COUNTY ROAD PERMIT NO. r LEGAL STATE ENCROACHMENT\ DESCRIPTION LOT N0._ .q PERMIT NO. BLOCK J3 TRACT �®�+� WASTE APPROVAL \ SIZE OF LOTNO.OF-BLDGS. CHARGES N0W ON LOT BUILDE O I NGS �Rl�,ed• ACONNECTION CHARGE FEE NO. DESCRIPTION OF WORK V FEKJ REIMBURSEMENT FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER G $ 3.60 RECEIPT NO. I DATX I BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION/RECORDED WORK TO HOUSE SEWER 1.00 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 CONNEION DATA SEPTIC TANK,SEEPAGE PIT OR PITS AND/ORDRAINFIELD 2.00 STATIONDEPTH CESSPOOL—O RYW ELL SPECIAL CONDITIONS ONLY 2.00 MANHOLEE REFERENCE LOWER i I� TYPE OF CONNECTION LENGTH.FROM OWNERS PERMIT 1 00 Y. CURB P.L. M.L.TO P.L. AUTHORIZATION I TOTAL FEE I L16 & I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED, CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING-. APPROVALS IN PECTOR'SSIGNATURE DATE DWELLING TO THE-PUBLIC SEWER SIGNED THIS_.._._....._.-_DAY OF...... ___w._.._.r..19� NEW ROUSE SEWER OWNER OR CONNECT ADDITIONAL f r OWNERS AGENhTT..... __,. � _� BUILDING OR WORK . lf ._ _ GL!fZ�' - SEPTIC TANK,SEEP.PIT(8) ADDRESS --._ AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS• ALTER,REPAIR,BE OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1. HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT 1 AM THE.LEGAL OWN- ER OF THE ABOV�W__ IBED R SIDE IAL PROP TY. BACKFILL SEPTIC TANKS SIGNATURE - SEEP.PIT(S)� CESSPOOLB�OFPERMITTEE.._ ._ dam .._ _. _ _ . 76A642A 663 7/63 WORKERS' COMPENSATION DECLARATION 20-0051 DPW 6i89 I hereby affirm that I ho,ie a certificate of consent to self Insure, bre certifi+ccite,of Workers'Compensation Insurance, or 76A&42D a certified copy thereof (Sec, 3800, Lab C , APPLICATION FOR PERMIT Pahcy'Nc. —_Company__-------------__-._ SEWER - SEWAGE DISPOSAL ❑ Certified copy is hereby furnished. ❑ 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" BUILDINGLYn� 7�✓, STATION DEPTH COMPENSATION iNSURANCE goDRESS 1vV L. A (This section need not be completed it the work involved 6y the LOCALITY � j,� ��-fS„ Ce� �/a McMANHOLEHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100)or less.) l! IPE of c I certlf that in the performance of the work for which this NEAREST CONNECTION eNGTHRgM Y P CROSS ST. ,y CURB F L M L TO P I. permit is issued, 1 shall not employ any person in any manner LEGAL PC No so as to become subject to the Workers' Compensation Laws, DESCRIPTION LOT NO. J CC, IMP NO )08 NO Date _ Applicant BLOCK > TRACTJ ,Jt ;' TRU^iK PERMIT NO ROAD PERMIT NO '1 �q +1 E ASSESSOR r' V o Q 1 AFFIER EASEMENT RECORD 'NSTR NO DATE NOTICE TO APPLICANT: If, after making this Certificate of MAP BOOK -:3 --A PAG E PgaceL �,{ Exemption, you should become subject to the Workers' }} NO.OF BLDGs DAVIT WAIV Compensation provisions of the Labor code. you must forthwith SIZE OF LOT ISO NOW ON LOT HWY QRST WIDENING comply with such provisions or this permit shall be deemed USE OF revoked. BUiL61NGS LI'L-1 N STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION � � �, �� PERMIT NO I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Busi- MAIL � 1 I, ;HARGEs ness and Professions Code, and mADDRESS y license is in full force and _jC� effect. CITY " �{�. TEL NC�lb . c.ONNECT!OV CHARGE FEE License Number �Lic. Classt�n RE MBURSEMENT FEE . �, Contractor Dote CONTRACTORDISTRICT NO GROUP MAP PROCESSED By ADDRESS ✓ BK PC, - ❑ 1 am exempt under Sec. of the LA.Co. s CITY TEL.NO. G- Plumbing Code and/or Sec. _of the srgTE LIC o-INAL 0 LICENSE NO. CLASS CATE {�` VALIDATION Z B. & P. Code for the following reason NO. DESCRIPTION OF WORK FEE S O HOUSE SEWER CONNECTING Tb F'NAL H Date PAUC SEWER 5'r SEPTIC TANK SEEPAGE PIT OR IH Signature PTS AND OR DRAINFIELD 0.0. OWNER-BUILDER DECLARATION HOUSE SEWER CONNECTING To Z PR,yATE DISPOSAL SYSTEM — I hereby affirm that I am exempt.from the Contractor's License -ONNECT ADDITIONAL Bi.DG OR Law for the following reason (Secton 7031.5, Buisness and Pro- WORK TO HOUSE SEWER V RFU7W SEEPAGE PI` DRA:NFIEtD fessions Code!: FX-N CESSPOOr DRYWEIL MAIIHOLE ❑ 1, as owner of the property, or my employees with wages as ALTER REPAIR OR ABANDON HOUSE ;EWER OR DISPOSAL SYSTEM their sole compensation, will do the work.and the structure is riot intended or offered for sole (Section 7044, Business and Professions Code). as owner of the property, am exclusively coni actinq with OWNER'S Permit $ r G Q licensed contractors to construct the project (Section 7044, _ x Business and Professions Code). AUTHORIZATION TOTAL FEE J CONSTRUCTION LENDING AGENCY HAVE AT THIS E A CONTRACT W*H THE HEREIN NAMED �?NTRA,_TUR TO I hereby affirm. that there is a construction lending agency CONNECT THE AAc-vE u SCR BED EXISTING DWELLING TO THE P Ie Ic SEWER for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.1. SIGNED THIS DAY OF 19_ .. WNER OR _ Lender's Name_--__ _—.._ OWNERS AGENT Lender's Address ADDRESS I certify That I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State lows regulating Plumbing and Sewers; and hereby authorize rep�pre,�yfor of this County to enter upon the above-menti einspections purposes A Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE •WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 92-0002 DPW 3,B, insure, or a certificate of Workers'Compensation Insurance, or 76A6d2D a certified copy thereof (Sec. 3800, Lab C.) CE BDB APPLICATION FOR PERMIT Policy No. Company _ 0t ❑ 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' BUILDINGSTATION DEPTH COMPENSATION INSURANCE ADDRESS Q C_)A L Q, (This section need not be completed if the work involved b the UPPER y LOCALITY MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this cRoss sr. v, CURB P.I. M,.L,TO P.L. permit is issued, I shall not employ any person in any an r ,,ii ,l P.C.No. so as to become subject t the Worker ' Comp n L w m �,� P, 2V LF -,1 �t �y Q�r�\ OWNER n ,'J� / CO.IMP.NO. JOB NO. -�-�y��pp 1� MAIL a M1.7`yv LJ�6 �� Date licant ` ADDRESS �� '� TRUNK PERMIT NO. ROAD PERMIT NO. ( �� AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY �L� G T£L.NO. 30 Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTIGN LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT . LICENSED CONTRACTORS DECLARATION slz£of LOT NOOF BLDGS. PERMIT NO. � D Now IN Lor I hereby affirm that I am licensed under provisions of Chapter USE of 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTORSG LE .% -- CONNECTION CHARGE FEE License Number LIC.Class ADDRESS REIMBURSEMENT FEE 0 Contractor Date CITY TEL.NO. DISTRICT NO. GROUP MAP PROCE)SED BY! O -r BK PG - . Z El am exempt under Sec. of the L.A.Co. STATE tic O LICENSE NO. CLA55 " f(ry '- H Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL U ff HOUSE SEWER CONNECTING TO DATE VALIDATION W B. $ P. Code for the following reason d PUBLIC SEWER �- 2(p SEPTIC TANK,SEEPAGE PIT OR FINAL Z_ PITS AND/CR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG:OR lop,DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD - - 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 esslOnS Code): SEWER OR DISPOSAL SYSTEM 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 K/1 El1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE i licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code), CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19_ for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all County ordinances and State laws regulating Plumbing and Sewers, ; and hereby authorize represe toT� for of this County to enter , upon the c ove-m pr e inspection purpose Signat e of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE