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Home My Public Portal About5036 ROSEMEAD BLVD_Sewer__ 9808-D 0APPLICATION FOR PERMIT eeoe•e•se COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING ADDRESS JOHN A. LAMBIE, County Engineer CASSATT D. GRIFFIN, Sup't of Building LOCALITY FOR APPLICANT TO FILL IN NEAREST M ceoss sr. ��..��•�:� LEGAL / OWNER , • DESCRIPTION LOT N0. //l BLOCK TRACTAIL / (f ? M 3 7S .J ADDRESS NO.OF BL GS. SIZE OF LOT NOW ON LOT CITY TEL.N0. BUELDINGS �~ DISTRICT N0. GROUP - MAP PROCESSED BY US0BK PG CONTRACTOR CALIF. SEWER CONST.CO. ' ADDRESS 1317 CQLEGROVE AVE. CONNECTION DATA CITYONTEELLtEL.NO- 1-5048 STATION �J DEPTH 7� ' / STATE MANHOLE REFERENCE REGISTRATION NO. 18076 6 q (STA l EA ® COUNTY LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $3.00 SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION'! LENGTHTO IFR FROM /P:L.6 .PITS AND/OR DRAINFIELD @ $3.00 Y. CURB M.L. OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 HOUSE SEWER CONNECTING TOP*C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. 40 JOB N0. CONNECT ADDITIONAL BLDG.OR - TRUNK PERMIT NO. ROAD PERMIT NO. WORK TO HOUSE SEWER @ $1.00 SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT . PERMIT N0. INDUSTRIAL , WASTE APPROVAL CHARGES OWNER'S PERMIT 2 DO CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE d REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ' TO THE PUBLIC SEWER. !' SIGNED THIS AY OF 19 NEW HOUSE,SEWER OWNER OR CONNECT ADDITIONAL " OWNERS AGENT BUILDING OR WORK SEPTIC TANK,SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPE LY GISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY ANGEL C TY AND TATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I TH LEG 0 N R OF T E ABOVE DESCRIBED RESIDENTI PROP ACKFILL SEPT- e may, SIGNATURE s;);`'+-fey"ZI-T-C-9� CESSPOOLS ,.�! '"��.5 r, ✓• ('Jy -•C+'TJ OF PERMITTE ®r AMATION ROBERT A.WOOD CR. M.D, CASH SUPERVISING MECHANICAL ENGINEER ,Co 5 8 9 9 APR 3 0 1 u A 5.�� 0 t7 ,.,.WORKERS'COMPENSATION DECLARATION l�horeby affirm that 1 have a certificate of consent to self `'nsure, or a certificate of Workers'Compensation Insurance, or 7sAsaxD a certified copy thereof ecG.� 00, Lab C.) 92-0002 DPW 8,99 APPLICATION FOR PERMIT Policy.t ocai n Certified copy is hereby furnished. SEWER SEWAGE DISPOSAL fi�tertified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departt. e Date i Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATECOMPENSATION IINSURAN EPTION FROM ORKER ADDRESSBUILDING 03( 'JJD p�BS�t++G � STATION o� Q DEPTH (This section need not be completed if the work involved by the LOCALITYMANHOLE REFERENCE V G� U R permit is for one hundred dollars ($100)or less.) L I certifythat in the NEAREST / TYPE OF CONNECT ON LENGTH F OM performance of the work for which this CROSS ST. /+.� Y. CURB L. M.L.T P. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER t— � � J�� P.C.NO. CO.IMP.NO. JOB NO. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS NOTICE TO APPLICANT: If, after makingthis Certificate Of ` AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY TEL.NO. l�r, 'f/ Exemption, you should become subject to the Workers' LEGAL 1 Compensation provisions of the Labor code, you must forthwith DESCRIPTION LOT NO. 1 HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed 2 revoked. BLOCK TRACT �f�J STATE ENCROACHMENT LICENSED CONTRACTORS DECLARATIONS' NO.OF BLDGS. ' PERMIT NO. SIZE OF LOT O NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF r 9 (commencing with Section 7000) of Division 3 Of the BUST- BUILDINGS 5 r P, CHARGES ness and Professions Code, and my license is in full force and py_r effect. CONTRACTOR Ll N1 1Fl / t9 � N CJJ3 a CONNECTION CHARGE FEE yF/ License Numb r LIC.Class ADDRESS O REIMBURSEMENT FEE 8 Contractor ate 1�T/ CITY lJr TEL.NO. Vly _ �7� DISTRICT NO. GROUP MAP PROCESSED BY Z PG BK r1 , N El STATE LIC. I am exempt under Sec. Of the L.A.CO. LICENSE NO. ®� �- CLASS '�(\J Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL VALIDATION HOUSE SEWER CONNECTING TO DATE B. 8 P. Code for the following reason PUBLIC SEWERSEPTIC TANK,SEEPAGE PIT OR - PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO '- BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER lJ 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 Lw fessions 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 isnot intended or offered for sale (Section 7044, Business _�%i,•' ,± it and Professions Code). OWNER'S Permit $ e' B property, y g TOTAL FEE _ ` "'-1?-' ❑ I,as owner of the am exclusive) contracting with AUTHORIZATION � licensed contractors to construct the project Section 7044, I '% 27 . 00 P I ( I HAVE AT iH15 DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR �� Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - CONSTRUCTION LENDING AGENCY � ti� << I hereby affirm that there is a construction lending agency SIGNED THIS v DAY OF19 for the performance of the work for which this permit is OWNER A Lu-r7d�.� !" � E?;il-3C ,��1_: issued (Sec. 3097, Civ. C.). OWNERS AGENT `.S�f/.�rl /'IR,N ADDRESS 3BGo � Y/��_�yd /a/�- e44111!5:91 Lender's Name Ei-(. Lender's Address I certify that I have read this application and state that the =1 " 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 upon he above-mentioned property for inspection purposes. Yom"" sir—7—/ Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE