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Home My Public Portal About6157 RENO AVE_Sewer__ 6 ? 7 V� 6A 6421) APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING DRF JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS S COLEMAN W. JENKINS. SUP T. OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. (PRINT OR TYPE ONLY) -A. DESCRIPTION OWNER MAIL BLOCK TRACT ADDRESS NO OF SLOGS. SIZE OF LOT.:& NOW ON LOT Y CIT NO, USE OF R � AP PROCE scEri By S law"z DISTRICT 0 CLASS 'd AP SK PG IL GONTRACTO R _ADDRESS CONNECTION DATA CITY TEL. NO. STATION DEPTH 5"ACE UPPER—LIC LICENSE NO. CLASS MANHL OE REFEREN C LOWER E� DESCRIPTIOW 0 R TYPE OF CONNECT FEE T 'i N LENGTH FROM HOUSE SEWER CONNECTING TO Y CURB L. M.L.TO'F PUBLIC SEWER @ $5.00 '' P.Cbtcr�— -ot PETSIC FANK SEEPAGE PIT OR AND/OR DRAINFirLD @ s10-00 No. HOUSE. WER CONNECTING TO TRUNK PERMIT NO. R PERMIT NO. >- PRIVATE iSPO-AL SYSTEM $3.00 CL ftft.N 0. CONNECT ADDiTIONAL.�� AFFIDAVIT sEMENT RECORD. IN DATE 7 WORK TO HOUSE SEWER $3.00 J_ OVERFLOWS EPAGE PIT.DRAINFIELD EX7N..CESSPOOL.DRYWELL,MANHOLE 0 $5,00 All ER.—--A I R'0 R HWY.OR ST.WIDENING 0 ABANDON HOUSE SE)OILER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT uj PERMIT NO, --I N DUSTRIAE WASTE APPROVAL z ________ UTHCHARGES OWNER'S PERMIT 00 CONNECTION CHARGE FEE AORIZATION TOTAL FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACT-OR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE P USLIC SEWER. -APPROVALS DATE T SIGNATURE SIGNED THIS-DAY OF _l 9_ OWNER OR _NEW HOUSE SEWER OWNERS AGENT— CONNECT ADDITIONAL ADpRESS BUILDING OR WORK SEPTIC TANK SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR orA!NFIEL(3 If AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ oRYWELL LJ -4--4 PROPERLY REGISTERED AND/OR --E REPAIR,SEWER I F(�REBY CERTIFY THAT I AM ALTER, OR LICENSED AS REQUIRED By LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM A L FO"N 1 A OR THAT I AM THE: LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN. T H E ABOVE DEGCqJBED.,R DENTIAL PROPERTY, ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ISEEP.P]T(S) ❑ CESSPOOLS oli VAIMATIPN JACK R. ALLEN CK. M.0. cgsHSUPERVISING MECHANICAL ENGINEER WORKERS'COMPENSATION DECLARATION I herebAaffirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or `,A642D a certified copy thereof (Sec. 3800, Lab C. C'E 808 REV,1 81 APPLICATION FOR PERMIT lJ Policy No. Company ❑ 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 r a STATION DEPTH COMPENSATION INSURANCE ADDRESS ✓ (This section need not be completed if the work involved by the —.-� MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) ocAurY t Lowen NEAREST - ;3 TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. Y. CURB P L. M L.TO P L. permit is issued, I shall not employ any person in any manner P.C.NO, so as to become subject to the Workers' Compensation laws. OWNER CO IMP.NO, JOB NO. MAILJ ADDRESS y +t TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant y . AFFIDAVIT I WAIVER EASEMENT RECORD.INSTR.NO, DATE NOTIE T APPL CANT: If, after making this Certificate of CITY o Exemption, you should become subject to the WorkersLEGAL 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 STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATION _ NO.of PERMIT No. LOT SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE of 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS ' CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number LIG Class ADDRESS REIMBURSEMENT FEE a Contractor Date CITY TELDISTRICT NO. GROUP BK MAP P OCESSED BY PG V .NO . El am exem t under Sec. of the L.A. Co. STATE LIC CL ow P LICENSE NO. CLASS Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL (~j HOUSE SEWER CONNECTING TO DATEVALIDATION W B. & P. Code for the following reason PUBLIC SEWER H SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFiELD " Z Date HOUSE SEWER CONNECTING TO BY { (°. PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG OR OWNER-BUILDER DECLARATION �XJWORK TO HOUSE SEWER , _. tf. � ✓ _ , 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 fes,sions 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/r Is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER=S Permit $ L� ❑ I, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE 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 ' , 1 hereby affirm that there is a construction lending agency SIGNED THIS .17, DAY OF � 19 for the performance of the work for which this permit is OWNER 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 representatives of this County to enter r=- upon the above-mentioned property for inspection purposes. Y 4'- I gnature o Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE