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HomeMy Public PortalAbout5318 ROSEMEAD BLVD_Sewer__ �.. 7 S.&E-663 11.55 APPLICATION FOR ERyIq DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL Department of.County Engineer County of Los Angeles BUILDING JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS ,� ® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY ^ FO APPLICANT TO FILL IN CROST x SNEAREST. T. LEGAL OWNER DESCRIPTION LOT N0. � -�C MAIL BLOCK TRACT ADDRESS N0. OF BLDGS. / CITY TEL, N0. SIZE OF LOT NOW ON LOT USE OF ' DISTRICT NO. GROUP MAP BUILbINGS - .� " s C f � BK PG CONTRACTOR CALIF. SE,11ER CONST.CO. ` RZ77 [____ .. ADDRESS 1317 CfL=GCQyC AVE. CONNECTION DATA A CITY NqCNTEBELTEL. NO. PA. 1-5048 STATION � � DEPTH MANHOLE REFERENCE /_ 180767 (STATE) ❑ STATE LOWER . REGISTRATION NO. ❑ COUNTY NO. DESCRIPTION OF WORK FEE f TYPE OF CONNECTION//� LENGTH FROM HOUSE SEWER CONNECTING TO )!- CURB /ff'L� M.L. TO.P.L. 1 PUBLIC SEWER @ $3�0 SEPTIC TANK,SEEPAGE PIT OR PITS AND/OR DRAINFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAINFIELDP, C'. NO, EXTN.,CESSPOOL,DRYWE LLMdkkN*d�E @ $2.00 CO. IMP. N0. �/} ljI JOB NO. HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. CONNECT ADDITIONAL BLDG.OR - STATE ENCROACHMENT WORK TO HOUSE SEWER Q $1.00 PERMIT NO. ALTER;REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNERS PERMIT a 00 REIMBURSEMENT FEE AUTHORIZATION I TOTAL 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 S W NEW HOUSE SEWER T SIGNED THIS DAY OF w 1 � CONNECT ADDITIONAL 14 OWNER ORCUC`'c�c-�- BUILDING OR WORK OWNERS AGENT �-- SEPTIC TANK,SEEP,PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE 'LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM ' I HEREBY CERTIFY THAT I PROP RL Y REGISTERED AND/OR DISCONNECT PLUG AND- LICENSED AS REQUIRED BY OS GEL C TY AND S A7E OF CALIFORNIA OR THAT 1. M .TH LEG L 0 N R OF T ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDENTIA ROP BACKFILL yc•crt�'•C SIGNATURE CESSPOOLS le OF PERMITTEE JOHN A. LAMB IE. COUNTY EN I ALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR - CK. M.O. CASH ' C 808.D APPLICATION FOR PERMIT eos.e-sa COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER :• t BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engineer ADDRESS CASSATT D. GRIFFIN, Sup't of Building LOCALITY NEAREST LEGAL FOR APPLICANT TO FILL IN _CROSS ST. DESCRIPTION LOT NO. OWNER BLOCK TRACT . MAIL ADDRESS N0. BLDGS. SIZE OF LOT NO ON LOT CITY TEL.NO. USE OF BUILDINGS -� DISTRICT NO. GR� BK MAP P6` d�� �- PROCESSED BY ' CONTRACTOR CALI S 1•-hI E R C 0 N ST.CO. ADDRESS h 1317 CO 1.L G i vr'E AV E. _ CONNECTION DATA CITY MONTEBE I rTEL. NO. 1-5048 STATIONDEPTH REGISTRATION N0. 180767 ❑i/i �1)E} STATE MANHOLE REFERENCE UPPER❑ COUNTY LOWER •, No. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ $8.00 SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNEC ON LENGTH FROM PITS AND/OR DRAINFIELD @ $8.00 Y. CURB P.L. M.L.TO P.L. OVERFLOW SEEPAGE PIT, DRAINFIELD EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 HOUSE_! CONN�CTfN TO P.C.NO. PRIVATE .@-$1.00 CO.IMP.NO. a JOB NO. CONNECT ADDITIONAL BLDG.OR I TRUNK PERMIT NO. ROAD PERMIT NO. WORK TO HOUSE SEWER @ $1.00 ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT_ SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. INDUSTRIAL WASTE APPROVAL CHARGES OVMER'S PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE S7 REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS gDATEINSPECTOR'S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGTO THE PUBLIC SEW R SIGNED THIS F "tZ CONNECT NEW HOUSE SEWER Y OiOWNER OR OWNERSAGENT R WORBUILDING OR �• ��✓a �f' 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 CERTIFYTHA I AM PRO RLY REGI ERED AND/OR DISCONNECT PLUG AND LICENSED AS REpUIR Y OS 1 L S COUNT AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR TH I A TH L OWNE OF THE VE DESCRIBED RESID TIAL t SEEPFILL SEP❑C TANKCESSP00❑LS SIGNATURE OF PERMITTE ®� VALIDATION ROBERT A.WOOD CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER G 2 5 5L., -MAY 6 :1 0 A �a'COMPENSATION DECLARATION that I have a ,certificate of consent to self 92-0002 DPW 3/87 insure, or a certificate CE 808 of Workers'Compensation Insurance, or D a certified copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No. Company es ❑ 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.p Date 'O—7' Applicant0*ffl"Y// SW O FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING �^^moi N. �5�� Lv p, STATION DEPTH COMPENSATION INSURANCE ADDRESS ,,JJ (This section need not be completed if the work involved by the LOCALITY ',e &,'o r MANHOLE REFERENCE UPPER LOWER permit is for one hundred dollars ($100)or less.) NEAREST Lr A TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. � 1G Af Eiy Q 9 RO ,0 W 4 y Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. OWNER L,;7"p 11,V tV 41 CO.IMP.NO. JOB NO. MAIL-�- J-,��fZy /� ADDRESS c �-y TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant / /L(, 7 3fr — ' l ^ 01 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making/this Certificate of CITY L /LJ /t�Q TEL.No�� c7 � L/ / Exemption, you should become subject to the Workers' LEGAL 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 BLDGS. PERMIT NO. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter TSE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS Al c) Te L CHARGES ness and Professions Code, and my license is in full force and A effect. CONTRACTOR R+ IAI D �� &5T. CONNECTION CHARGE FEE /3— e� � License Number Lic.Class / ADDRESS /,3 (� (�° 1.iv REIMBURSEMENT FEE O [� ConTracTorL1",rRRyM p �!r ►3 `/J / DISTRICT NO, GROUP MAP PROCESSED BY Date CITY CrL ��(� TELN . ❑ I am exempt un/der Sec. of the L.A.Co. LICENSE NO. cLAss / 'J.(s a(/ �j 2 v Plumbing Code and/or Sec. of the NO. DESCRIPTION OF WOK FEE FINAL � HOUSE SEWER CONNECTING TO DATE VALID ION B. & P. Code for the following reason PUBLIC SEWER -� N SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIEID Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR ► OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER 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 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 and Professions Code). OWNERS Permit $ AUTHORIZATION 4z937.o 0 0 0 ❑ I,as owner of the property, am exclusively contracting with TOTAL FEE 1 - - 27.50 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. o a o 2 7.5.6 E CONSTRUCTION LENDING AGENCY , OIL 1 3,-88 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 issued (Sec. 3097, Civ. C.). OWNERS AGENT 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 ordinancesd State laws regulating Plumbing and Sewers, and hereby Thor, ze repe tatives of this County to enter upon The 4e-mentione/d/pyperty for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE �n&tfOF-NERS'COMPENSATION DECLARATION {irm that, I Piave a certificate of consent to self 96-0002 DPW 3/87 !cert;ficcp of Workers'Compensation Insurance, or CE 808 D a gentiPd copy thereof (Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No. Company OS ❑ 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. Dater 2-E_Applicant L765fmY�a/t/() F11G FOR APPLICANT TO FILL IN ^ 1 CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' ✓ STATION DEPTH COMPENSATION INSURANCE o !!!///���(This section need not be completed if the work involved by theL� MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) LOWER TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this C 0 1� O /7 Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. o P.C.NO. I P OWNER CO.IMP.NO. JOB NO. /� � ��jj�� �' p N POA MAIL l r }) TRUNK PERMIT NO. ROAD PERMIT NO. Dated'U// Applicant L/ I1►`� / ✓I"v b ADDRESS '4pC Sp J `ff� NOTICE TO APPLICANT: If, after makingthis Certificate o{ AL A i2 AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY /„ TEL.�O. �— Exemption, you should become subject to the Workers' LEGAL 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 BLDGS. PERMIT NO, 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. \l n l CONTRACTOR ' t ©N(J r.) y CONNECTION CHARGE FEE License Number I d / _Llc.Class 5— / ADDRESS 13' (7sloA �,�(/ jLJLJ REIMBURSEMENT FEE O A Date �— /—UlJ /J i7 l DISTRICT NO, GROUP MAP PROCES D BY (, CITY G.�Ie+tT !O TEL.NO. p[ klO1 t� ///� PG Contractor vy/ ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. a 69 / LIC 0 NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the L HOUSE SEWER CONNECTING TO DATE ' VALIDAT w B. & P. Code for the following reasonot PUBLIC SEWER W SEPTIC TANK,SEEPAGE PIT OR FINAL _� PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRYWELL,MANHOLE 9 3 7.�'A' Law for the following reason (Sectors 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE G fessions Code): SEWER OR DISPOSAL SYSTEM ❑ 1,as owner of the property,or my employees with wages as o o020 7 8 their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business Permit $ 0 0 a 2 7.5 Q Cz and Professions Code). OWNERS O , 'J,_8,'8 ❑ 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 CONTRACTITOBusiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ,I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 1 for the performance of the work for which this permit is OWNER OR Poo- issued (Sec. 3097, Civ. C.). OWNERS AGENT 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, ar, ereby author'ze representatives of this County to enter up' n the above-gntioned property for inspection purposes. Ll-1)- ignature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE