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Home My Public Portal About5124 ROSEMEAD BLVD_Sewer__ \ t CE83APPLICATION FOR PER T 76A64642D � �•. 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 BUILDING LOCALITY NEAREST FK OR APPLICANT TO FILL IN CROS ST. 74 L .�..�n TION LOT NO. OWNER MAIL TRACT J\ U -��l` ADDRESS NO. OF BLDGS. LOT NOW ON LOT CITY TEL. NO. y DISTRICT NO. GROUP MAP PROCESSED BY GS `// BK PG �a yTOR e / CO NECTION DATA r STATION DEPTH / EL., NO LSC MANHOLE RE,FERENCEUPPER NO:; GLASS NO. DESCRIPrroN OF WORK FEE TYPE OF CON NECTIO LENGTH F OM HOUSE SEWER CONNECTING TO ^ Y. CURB P. M.L.TO L. a PUBLIC SEWER @ $5.00 `J SEPTIC TANK.SEEPAGE PIT OR P .NO. O PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. JOB NO. 1J HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Ix PRIVATE DISPOSAL SYSTEM @ S3.00 O CONNECT ADDITIONAL BLDG.OR AFFIDAVI AIVEl EASEMENT RECORD. INSTR.NO, DATE WORK TO HOUSE SEWER @ $3.00 OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00 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 S, i 00 AUTHORIZATION rTOTAL FEE 1 Z6 1 gv 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 SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ c OWNER OR NEW HOUSE SEWER •�6- O OWNERS AGENT_ CONNECT ADDITIONAL BUILDING OR WORK ADDRESS SEPTIC TANK.SEEP,PIT(S) I HEREBY ACKNOWLEDGE THAT 1 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 ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/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 RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER F SIGNATURE BACKFILL SEPTIC TANKS ❑ OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK M.O. CASH err 3t---" 1 0.00- 6 �.. v WORKERS'COMPENSATION DECLARATION CE 808 (D2-80) 77C, APPLICATION FOR PERMIT I hereby affirm that I have a certificate of consent to self SEWER-SEWAGE DISPOSAL insure, or a certificate of Workers'Compensation Insurance,or a certified co hereof(Sec. 3800,L�f� COUNTY OF LOS ANGELES BUILDING AND SAFETY Policy No. -s��P mpan�, ❑ Certified copy is hereby furnished. FOR APPLICANT TO FILL IN CONNECTION DATA BUILDING STATION DEPTH Certified copy is filed with the co my bu'Id'MM427 ction ADDRESS -A j'' UPPER deparrtt�me—nt�y/q t179yLJzv" LOCALITY" l� - MANHOLE REFERENCE LOWER Dat e/Cr-� —ZA licant �?_ PP NEAREST TV PE 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 .sJ - CO. IMP. NO. JOB NO. (This section need not be completed if the Work involved ADDRESSTRUNK PERMIT NO. ROAD,PERMIT NO. d by the permit is for one hundred dollars0, ($100) Or less.) CITY Z TEL. NO. ZZ7Z`Z � AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE U i�I I certify that in the performance of the work for which this LEGAL permit is issued, I shall not employ any person in any manner DESCRIPTION LOT NO. HWY. OR ST. WIDENING so as to become subject to the Workers' Compensation Laws. U BLOCK TRACT STATE ENCROACHMENT W Date Applicant NO. OF BLD GS. PERMIT NO. a- NOTICE TO APPLICANT: If, after making this Certificate of SIZE OF LOT NOW ON LOT d3� � Exemption, you should become subject to the Workers' USE OF CHARGES Compensation provisions of the Labor Code, you must forth- BUILDINGS With comply with SUCK provisions or this permit Shall be ! CONNECTION CHARGE FEE deemed revoked. CONTRACTOR o. /tVJ G�/C� • �• �J. LICENSED CONTRACTORS DECLARATIONADDRESS �� REIMBURSEMENT FEE I hereby affirm that I am licensed under provisions of Chapter ^_ DISTRICT NO. GROUP MAP PROCESSED BY 9 (commencing with Section 7000) of Division 3 of the Busi- clrY �r TEL. No. — �� BK PG _ ness and Professions Code, and my license is in full force and STATE LICENSE NO.23�7 i 7 -7 LIC. CLASS effect. NO. DESCRIPTION OF WORK FEE /� ' 3 HOUSE SEWER CONNECTING TO FINAL )��y� W2 VALIDATION License Number Lic.Class [[�� PUBLIC SEWER DATE _ ,. y1 1-22 !! +� [�� SEPTIC TANK,SEEPAGE PIT OR �1�I, /�� 2 / tl� PITS AND/OR DRAINFIELD 1" Contractor />/� C✓/� Date G L FINAL !/F. HOUSE SEWER CONNECTING TO J _ 1 PRIVATE DISPOSAL SYSTEM ❑ BY I am exempt from the licensing requirements as I am a CONNECT ADDITIONAL BLDG.OR licensed architect Or a registered professional engineer WORK TO HOUSE SEWER qqq acting In my professional capacity (Section 7051, Bus- OVERFLOW SEEPAGE PIT, DRAINFIELD ;//�� Ines$and Professions Code). EXTN.,CESSPOOL,ORYWELL,MANHOLE tttJJJ 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 OWNER'S Permit f LS-0 License Law for the following reason (Section 7031.5, Busi- AUTHORIZATION TOTAL FEE �,3 L =6 ness and Professions Code): TRACT AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CG F1TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - 7 I, as owner of the property, will do the work and the TO THE PUBLIC SEW ERp.� _ structure is not intended or offered for sale (Section SIGNED THIS C/ DAY OF ff9/� ty o o'o G ( �, 7044, Business and Professions Code). OWNER OR OWNERS AGENT CONSTRUCTION LENDING AGENCY y o I' 5 C I. hereby affirm that there is a construction lending agency A11RE55 for the performance of the work for which this permit is ;(_1 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 representatives of this County to enter ;Unt1 above-men W Iced property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 0, 2 Signatur o ermittee Date