The URL can be used to link to this page

Home My Public Portal About5116 ROSEMEAD BLVD_Sewer__ r DEPARTXENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL .DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES, WILLIAM J. FOX, COUNTY ENt3INEERI BUILDING ADDRESS j FOR APPLICANT TO FILL IN LOCALITY --T C BUILDING ) t f% NEAREST ADDRESS / (� GROSS ST. ��N L LOCALITY DISTRICT N0. Ready for Inspection PERMIT NO. �'. . 363 _3 NEAREST � � + S CROSS ST. RECEIVED BY DATEISSUED BY DATE OWNER - t 49 MAIL ADDRESS ___ USE ZONE OCCUPAN Y BK MAP PG F I CITY TEL.MO. r CONTRACTOR CO.IMP.N0. ADDRESS JOB.NO. CITY TEL.NO. TRUNK PERMIT NO. STATE REGISTRATION NO. COUNTY ROAD PERMIT NO. LEGAL L' w STATE ENCROAC NT DESCRIPTION LOT N0. ^7 /� PERMIT NO. " BLOCKf TRACT �� S� s�l ��3 WASTE DUTRI&L-" PROVAL SIZE OF LOT NO.OF BLDGS. NOW ON LOT CHARGES USOF BUE DINGS CONNECTION CHARGE FEE NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FES HOUSE SEWER CONNECTING TO _ PUBLIC SEWER 64 : 3.50 RECEIPT NO. DATE BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 _L CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED WORK TO HOUSE SEWER 1.00 NO. I DATE I BY ALTER OR REPAIR TI EXISNG SEWER OR DISPOSAL SYSTEM 1.00 DISCONNECT AND ABANDON SEWER _ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK.SEEPAGE PIT OR PITS AND/OR DR_AINFIELO 2.00 AL3 STATION DEPTH . CESSPOOL—DRYWELL SPECIAL CONDITIONS ONLY 2.00 A#IHOeLEERREFERENCE UUff�t LOWER TYPE OF CONNECTIONLENGTH FROM OWNERS PERMIT s ( Y. CURB P.L. L.TO P.L. 00 AUTHORIZATION TOTAL FEE p 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS ECOR'SSIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS...__.._._-DAY OF__._._ 19NEW HOUSE SEWER ,� 1 Ills OWNER OR CONNECT ADDITIONAL OWNERS AGENT__-_.._..___---------_ BUILDING OR WORK SEPTIC TANK.SEEP. IT( ADDRESS...............-......___._._-..__....___.__._._.__.----_. AND/ORDRAINFIELL,. •. I 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL❑ CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTER— ED DISCONNECT PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER AND STATE OF CALIFORNIA OR THAT IAM TH LEGAL OWN- ER OF THE ABOY/"ESCRIBED RESIDENTIA OPERTY. BACKFILL SEPTIC TANKS E] SIGNATURE" s SEEP.PIT(S)� CESSPOOLS OF PERMITTEE...-_.'_ _ 76A642D S&E 663 4/54 WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a� 4. e�tificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof (Sec. 3800, f ) CE808(REV.8/81) APPLICATION FOR PERMIT Policy ' No.z iZCompany ( !4 ([t r I'ra Os [�yCertified copy is hereby furnished. SEWER - SEWAG ISPOSAL El Certified copy is filed with the county building inspection' COUNTY OF LOS ANGELES BUILDING AND SAFETY department. Date Applicant FOR APPLICANT TO FILL IN (` C Q CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDINGf i COMPENSATION INSURANCE ADDRESS e� dWe� �; STATION DEPTH (This section need not be completed if the work involved by theLOCALITY MANHOLE REFEREN f>¢QO — 7 permit is for one hundred dollars ($100)or less.) e� I '' LOWER NEAREST - 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. CL as to become subject to the Workers'Compensation Laws. OwN�R � CIS —e.-e� C 17/�0 C� CO.IMP.NO. JOB NO. MAILTRUNK PERMIT NO. ROAD PERMIT NO. Ltf ADDRESS��„ ""Ole Qge Date Applicant AIVER EASEMENT AFFIDAVIT WRECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY (9 �d y TEL.NO. 6- �y S Exemption, you should become subject to the Workers' LEGAL Lty 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 �, PERMIT NO. LICENSED CONTRACTORS DECLARATION SIZE OF LOT NO.OF BLDGS.NOW ON LOT /— I hereby affirm that I am licensed under provisions of Chapter USE OFr3A /S/3 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS tfrG CHARGES ness and Professions Code, and my license is in full force and effect. ry ( CONTRACTOR 1 /D f,/ CONNECTION CHARGE FEE License Number LIc.Class �' ADDRESS f 4� ((P� o Y� REIMBURSEMENT FEE i/ p CO Hiro Ciar Date _ CITY I�/ -(��e`n y DISTRICT NO. GROUP MAP PR CESSED BY C� / cT .NO.� v J ✓ PG 1 am exempt under Sec. of the L.A.Co. LICENSE NO. 47 f/,2 '2i CLASS � �� 3 � Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATEPUBLIC SEWER /, „-r �7 VALIDATION o B. & P. Code for the following reason SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY _ - PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER UILDER DECtARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT, I hereby affirm that I am.exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,EIL,MANHOLE Law for the following reason (Secton 7031.5, BUlsness and Pro- ALTER,REPAIR OR ABANDON HOUSE 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 is not intended or offered for sale (Section 7044, Business -_0'7'5 5 4 A and Professions Code). OWNER'S Permit $ X ISO ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEEt (Section 7044 , Q 4'.' o 0 70 0 1 Q licensed contractors to construct the project , 2.0'o-21250t P I ( I 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 , o o o 2 2 5 0 v 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 q issued (Sec. 3097, Civ. C.). OWNERS AGENT ' 1, 1 5-82 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 d to laws regulating Plumbing and Sewers, and hereoutho Ize r sentatives of this County to enter upon the {zv e toned property for inspection purposes. Signature/6f Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE