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Home My Public Portal About5122 ROSEMEAD BLVD_Sewer__ R 7EBQB 7BA84APPLICATION FOR PERMIT � u COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS , COLEMAN W. JENKINS. SUPT. OF BUILDINGq LOCALITY NEAREST FOR APPLICANT TO FILL IN CRQSB BT. LEGAL DESCRIPTION LOT NO. OWNER MAIL t BLOCK TRACT ADDRESS ) NO. OF BLDGS. SIZE OF LOT ,[IOW ON LOT CITY TEL. USE OF , BUILDINGS Z7 DISTRICT JNN^{O►. G•''��R'''0U777P e MAP �/-/� O SSED BY PG CONTRACTOR i� 7{ ADDRESS / CONNECTION DATA CITY T NO. '� STATION / _� F_ (/ DEPTH Or STATE L C MANHOLE REFERENCE/ •••// 1 UPPE LICENSE NO,. GLASS ( ' LOWER NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TOY. CURB .L. M.L.TO P.L. d PUBLIC SEWER @ $5.00 SEPTIC TANK,SEEPAGE PIT OR ^ P.C.NO. O PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. .108 NO. U HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM @ $3.00 O CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD,INSTR,NO. TE qq WORK TO HOUSE SEWER @ $3.00 ] 1/2/T�9•y / W OVERFLOW SEEPAGE PIT.DRAINFIELD l�G� EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00 C' ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING H SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OWNERS PERMIT $ 21 00 AUTHORIZATION I TOTAL FEE ^ CONNECTION CHARGE FEE IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWWER+2APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS_�_ DAY OF /' 19 '' OWNER OR J NEW HOUSE SEWER OWNERS AGENT / CONNECT ADDITIONAL ADDRESSlbi�_21 BUILDING OR WORK SEPTIC TANK.SEEP.PIT(S) I HEREBY ACKNOWLEDGE TH I HAVE 'READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN, THE ABOVE DESCRIBED E IDENTIAL PROPERT ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMfTTEE SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION JACK R. ALLEN CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER �r_.3 1 3 1c%;o' 0 X23 1 0 D 7.00N WORKERS'COMPENSATION DECLARATION 808 (2-80)D CE APPLICATION FOR PERMIT CE 808 I hereby affirm that I have a certificate of consent to self SEWER—S EW GE DISPOSAL insure, or a certificate of Workers Co ensation Insura ce,or a cert'f' .—'� here c�lf�� COUNTY OF LOS ANGEL BUILDING AND SAFETY Poli IT �J FOR APPLICANT TO FILL IN CONNECTION DATA E] Certified copy is hereby furnished. 1v( O�} /// / .BUILDING �'^'J -. � STATION �� ® DEPTH JI Certified copy is filed with the count building ADDRESS <J/ t!� p y g inspection UPPER department. LOCALITY ' MANHOLE REFERENCE A 7 P G��! LOWER Dat e ApphCant NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE �i,��ry P.C. NO. OWNER CO. IMP. NO. �V(JV JOB NO. MAIL ll (This Section need not be completed if the work Involved ADDRESSTRUNK PERMIT NO. ROAD PERMIT NO. O by the permit is for one hundred dollars ($100) or less.) G ITY TEL. NO. U AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE �� I certify that in the performance of the work for which this LEGAL er permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HW R IDEM �- 0 so as to become subject to the Workers' Compensation Laws. V BLOCK TRACT STATE ENCROAC 'MENT I,jJ Date Applicant NO. OF BLDGS. PERMIT NO. CL SIZE NOTICE TO APPLICANT: If, after making this Certificate of USE of of Lor NOW oN LOT Z Exemption, you should become subject to the Workers' USE BUILDINGS C A Compensation provisions of the Labor Code, you must forth- with comply with such provisions Or this permit shall be CONNECTION CHARGE FEE deemed revoked. CONTRACTOR REIMBURSEMENT FEE ADDRESS LICENSED CONTRACTORS DECLARATION ' I hereby affirm that I am licensed under provisions of Chapter ' DISTRICT NO. GROUP MAP PR OC sSED BY 9 (commencing with Section 7000) of Division 3 of the Busi- clrY S. S TEL. rvo. / � ness and Professions Code, and my license is in full force and STATE LIC. / �p LICENSE NO. CLASS L�' effect. ] NO. DESCRIPTION OF WORK FEE i /Y HOUSE SEWER CONNECTING TO FINAL T T '�•y-� VALIDATION License Nu Lic.Class PUBLIC SEWER DATE // �(/]✓ir r( ot SEPTIC TANK,SEEPAGE PIT OR I Q�- /'�r,�[ PITS AND/OR GRAINFIELD Contractorof' WDate / GGL 4/\ FINAL HOUSE SEWER CONNECTING TO BY F" PRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR d licensed architect or a registered professional engineer WORK TO HOUSE SEWER 7s.1(a acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD lness and Professions Code). E%TN.,CESSPOOL.DRYWELL. MANHOLE ALTER, REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION 2 2 9 0 9 A I hereby affirm that I am exempt from the Contractor's OWNERS Permit S License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE $ 0 0 0 0 ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- 2!o.o 2 2.5 0 TRACTOR TO CONNECT THE ABOVE DESCR ED XISTING DWELLING I D I, as owner of the property, will do the work and the TO THE PUBLIC SENP. ,� 0 0 0"o StIUCtUie is not intended or offered for sale (Section SIGNED THIS DAY OF `L. 19� 2 L' '" O 7044, Business and Professions Code). � OWNER OR // d � OWNERS AGENT /IIV�S'f` O 2,0 9°-8 2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ADDRESS ' for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). 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 repr senti-t' es of this County to enter up h b ve-menti e pr y for inspectio pure ses. SEE REVERSE FOR EXPLANATORY LANGUAGE ' natuf�P rmittee-- Date rWOARERS'COMPENSATION DECLARATION 76 808�_801 APPLICATION FOR PERMIT hei-eby affirm that I have a certificate of consent to self S E Yv E R—S E t/'Y A I S POSA L insure, or a certificate of Workers'Co sation Insura e,or #,ti U e Sec. 0. � gI COUNTY OF LOS ANGEL L BUILDING AND SAFETY om any Certified copy is hereby furnished.f�5 / FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING �� STATION DEPTH Certified copy is filed with the county building inspection ADDRESS UPPER department. LOCALITYMANHOLE REFERENCE LOWER Date Applicant NEAREST o TYPE OF CONNECT LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' ceoss ST. Y. CURB P.L. M.L. TO P.L. q P.C. NO. COMPENSATION INSURANCE OWNER 1 _ CO. IMP. NO. V JOB NO. MAIL a (This 50CtlOn need not be completed if the WOIk InVOIVed ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. _ 0 by the permit Is for one hundred dollars ($lOO) OI IOSS.) AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE U CITY r TEL. NO. I certify that in the performance of the work for which this F LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. Hyyy. ID ING 0 so as to become subject to the Workers' Compensation Laws. (, .BLOCK TRACT STATE ENCROACHMENT Ijf Date Applicant NO. OF BLDGS. PERMIT NO. Q� NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT z ti Exemption, you should become subject to the Workers' USE OFBUILDINGS CHARGES Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE ; deemed revoked. REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS OJLeylld+�^ 1 hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP. MAP PR Es D BY 9 (commencing with Section 7006) of Division 3 of the Busi- CITY -r TEL. NO. BK PG ness and Professions Code, and my license is in full force and STATE LIC. i LICENSE NO. CLASS 5 74 effect. /^r/ - NO. DESCRIPTION OF WORK FEE v ' J HOUSE SEWER CONNECTING TO FINAL VALIDATION License Numb Lic.Lic.Class PUBLIC SEWER DATE Vp SEPTIC TANK,SEEPAGE PIT OR L!y PITS AND GRAINFIELD Contractor Date FINAL _ HOUSE SEWER CONNECTING TO BY aPRIVATE DISPOSAL SYSTEM I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT.DRAINFIELD / iness and Professions Code). EXTN.,CESSPOOL,DRYWELL,MANHOLE ALTER, RE IR OR ABANDON HOUSE SEWER O .IROS 5 TEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit ! License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESC D EXISTING DWELLI ' Ell, as owner of the property, will do tlie work and the TO THE PUBLIC se R. / -9 29 1.2 A structure is not intended or offered for sale (Section SIGNED THIS DAY OF Iso 7044, Business and Professions Code). OWNER OR J��//. [_.— OWNERSAGENT #'0'0 O O 5 4 CONSTRUCTION LENDING AGENCY ADDRESS o 0 I hereby affirm that there is a construction lending agency .2 4 Q,0 0 for the performance of the work for which this permit is ' 0 0 0 (G 0,0 20:issued(Sec. 3097,Civ.C.). c� Lender's Name .0209-82 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 re r s t• i s of this County, to enter W_menjio upro for inspection p rpose . SEE REVERSE FOR EXPLANATORY LANGUAGE IV r ;=tee rjtee Date WORKERS'COMPENSATION DECLARATION D CE 808 (2-80) APPLICATION FOR PERMIT CE 808 I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL � �insure, r certificate of Workers'Com nsation Insuran or of(Sec. 3800. L COUNTY OF LOS ANGELES BUILDING AND SAFETY ol• y C7� Company ❑ Certified copy is hereby furnished. � — FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING /' STATION DEPTH ertified copy is filed with the county building inspection ADDRESS /� UPPER ment. LOCALITY MANHOLE REFERENCE LOWER Date Applicant NEAREST TYPE OF CONNECT LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' cRoss ST. Y. CURB P. M.L. TO P.L. COMPENSATION INSURANCE P.C. NO. OWNER CO. IMP. NO.t/Y7' � B NO. MAIL (This section need not be completed if the work Involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. D. by the permit is for one hundred dollars ($100) or less.) AFFIDAVIT WAIVER EASEMENT RECORD, INSTR, NO. DATE t- CITY 1< TEL. NO. 0 I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. R T. l)G so as to become subject to the Workers' Compensation Laws. 0 BLOCK TRACT 5 ATE ENCROACHMEN /1 Date Applicant NO. OF BLDGS. PERMIT NO. ( W NOTICE TO APPLICANT: If, after making this Certificate of slzE of LOT Now ON LOT J Exemption, you should become subject to the Workers' USE OF fn Compensation provisions of the Labor Code, you must forth- BUILDINGS CHARGES I Z with comply with such provisions or this permit shall be CONTRACTOR CONNECTION CHARGE FEE deemed revoked. REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED BY 4, 9 (commencing with Section 7000) of Division 3 of the Busi- CITY �� TEL. NO. BK �PG ness and Professions Code, and my license is in full force and STATE LIC. r!`1 f/ , -151 effect. LICENSE NO. CLASS CfU NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO FINAL VALIDATION License Number Lic.Class PUBLIC SEWER DATE Jy2 AND/OR DRAINFIELD SEPTIC TANK,SEEPAGE PIT OR -* P_ 9 PITS Contractor Date d FINAL HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM ElI am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELD / J•� iness and Professions Code). E%TN.,CESSPOOL,DRYWELL,MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION ? I hereby affirm that I am exempt from the Contractor's OWNERS Permit i License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- G 9 1. 1 R YRACTOR TO CONNECT THE ABOVE DESCRIBE E TING DWELLING ❑ I, as owner of the property, will do tlie work and the TO THE PUBLIC SE structure is not intended or offered for sale (SectionSIGNED THIS DA 19� # o o'o 0 5 4 7044, Business and Professions Code). OWNER OR OWNERS AGE1C11CXK2!- 0 4 0 0 0 CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there is a construction lending agency 0'0 0 4 0,0 0:C U for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). 2 0 9-8 2 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 authorizer res • Ives of this County to enter up o a-m a erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnaturezQf P pti ee Date WORKERS'COMPENSATION DECLARATION D CE 808 (2-80) APPLICATION FOR PERMIT CE 808 I hereby affirm that I have a certificate of consent to self t SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insur nce,or a certified co hgreof c. 3800, Lab.C.) COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. ��a pany �i�i �� ( ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING r STATION DEPTH Certified copy is filed wi ' ty building inspection ADDRESS / ei„6! /'�� L-�® UPPER department' LOCALITY' �� MANHOLE REFERENCE LOWER Date 77 Applicant= NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION ROM WORKERS' CROSS sT. _ � L�-�G`G? Y. CURB P.L. M.L. TO P.L. //. P.C. NO. COMPENSATION INSURANCE OWNER lY j �/ �Ls {� CO. IMP. NO. JOB NO. MAIL 10, (This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. � by the permit is for one hundred dollars ($100) or less.) _ 0 AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. GATE CITY TEL. NO. � U I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. 0 BLOCK TRACT STATE ENCROACHMENT V Date Applicant NO. OF BLDGS. PERMIT NO. LU NOTICE TO APPLICANT: If, after making this Certificate of slzE of LOT NOW USE OF oN LOT �0 3� U) Exemption, you should become subject to the Workers' CHARGES Z Compensation provisions of the Labor Code, you must forth- BUILDINGS with comply with Such provisions or this permit shall be -fy� CONNECTION CHARGE FEE deemed revoked. CONTRACTOR a0 LICENSED CONTRACTORS DECLARATION ADDRESS le,�e� REIMBURSEMENT FEE I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP PROCESSED B� CIT ru TEL. NO. BK PG ! 9 (commencing with Section 7000) of Division 3 of the BusiST- ness and Professions Code, and my license is in full force and LICENSE NO. 9� cLAss � ,vJ �/ �0 effe Ct' /Jr��t /p /l NO. DESCRIPTION OF WORK FEE 3i/ /� /(,2(A ROUSE SEWER CONNECTING TO FINAL l�[ y� VALIDATION icense Numb 7 ! Lic.Class Ly TTT PUBLIC SEWER 15 DATE LA SEPTIC TANK,SEEPAGE PIT OR Contractor Date 1�� J��.� L PITS AND/OR DRAINFIELD FINAL ,J `_ MOUSE SEWER CONNECTING TO � - ❑ PRIVATE DISPOSAL SYSTEM BY I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting in my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD �! iness and Professions Code). EXTN.,CESSPOOL,DRYW ELL, MANHOLE ALTER,REPAIR OR ABANDON HOUSE SEWER OR DISPOSAL SYSTEM Lic.or Reg.No. Date e,_G oaf HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWNERS Permit f 60 License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE R- ,fD _ ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- G , ❑ TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING [, as owner of the property, will do the work and the TO THE PUBLIC SEWER. C o o u structure is not intended or offered for sale (Section SIGNED THIS O DA /V 19/ 7044, Business and Professions Code). OWNER OR - OWNERS AGENT CONSTRUCTION LENDING AGENCY ADDRESS Thereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.C.). �- Lender's Name Lender's Address I certify that 1 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 upon th above-mentioned property for inspection purposes. ` SEE REVERSE FOR EXPLANATORY LANGUAGE �S.gnatur of PermitteeDat / 76A642D WORKERS'COMPENSATION DECLARATION APPLICATIONCE 808 (2-80) FOR PERMIT I hereby affirm that I have a certificate of cons t to self SEWER-SEWAGE DISPOSAL insure, or a_c rtificate of Workers'Cc' nsation [ rance,or a certifie her es,_3800.L COUNTY OF LOS ANGE ES BUILDING AND SAFETY Policy omp�any ❑ Certif' d py ' hiby fuished. - FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION DEPTH Certified co is filed with the count building ADDRESS copy y g inspection UPPER de art Ment. a;tMANHOLE REFERENCE .'� dd .P LOCALI— LOWER Date Applicant NEAREST TYPE OF CONNECTION LENGTH FROM CERTIFICATE OF EXEMPTION FROM WORKERS' CROSS ST. Y. CURB P.L. M.L. TO P.L. COMPENSATION INSURANCE P.C. NO. OWNER C- . CO. IMP. NO�� JOB NO. MAIL (This section need not be completed if the work involved ADDRESS TRUNK PERMIT NO. ROAD PERMIT NO. by the permit is for one hundred dollars ($100) or less.) n AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE tL CITY TEL. NO. 1-0?a3� O I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HW IN so as to become subject to the Workers' Compensation Laws. i Q BLOCK TRACT "STATE ENCROAC ENT I-- Date Applicant NO. OF BLDGS. PERMIT NO. 0 W NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT L` ti Exemption, you should become subject to the Workers' USE OF to BUILDINGS CHAR Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall beCONNECTION CHARGE FEE deemed revoked. coNrRAcroR REIMBURSEMENT FEE LICENSED CONTRACTORS DECLARATION ADDRESS I hereby affirm that I am licensed under provisions of Chapter DISTRICT NO. GROUP MAP P CESS BY CITY `rEL. NO. BK PG 9 (commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license is in full force and LICENSE NO. CLASS 'U ' a effect. NO. DESCRIPTION OF WORK FEE C /lw HOUSE SEWER CONNECTING TO FINAL`n� VALIDATION License Numb Ic.Class PUBLIC SEWER DATE SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD Contractor Date �rd !� FINAL NOU SE SEWER CONNECTING TO ❑ PRIVATE DISPOSAL SYSTEM BY Y I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect or a registered professional engineer WORK TO HOUSE SEWER acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT,DRAINFIELO Y iness and Professions Code). EXTN.,CESSPOOL,DRYWELL, MANHOLE ALTER IR OR ABANDON HOUSE SEW OR D OSAL SYSTE Lic.or Reg.No. Date HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's OWN W'S Permit f License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE ness and Professions Code): I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- l•RACTOR TO CONNECT THE ABOVE DESCRIBED EXI ING DWELLING 2 9 1. A ❑ I, as owner of the property, will do ttie work and the TO THE PUBLICSEW FS structure is not intended or offered for sale (Section SIGNED THIS DAYpOFvx-lk- 19 #1 0 0 0 0 1 0 7044, Business and Professions Code). OWNER OR ! �! OWNERS AGENT ( 2 0 0 2 2 5 0 CONSTRUCTION LENDING AGENCY ADDRESS I hereby affirm that there is a construction lending agency '- 225060 0 = for the performance of the work for which this permit is 2 2.5 v issued(Sec. 3097,Civ.C.). 209-82 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 up t bove-me�ppertyr insp cti o purpos SEE REVERSE FOR EXPLANATORY LANGUAGE 41 Signature of P rmittee D to A0,21Q