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Home My Public Portal About6128-6138 ROSEMEAD BLVD_Sewer__ APPLICATION FOR PERMIT cs;eoa-a.�e COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE, County Engia"r CASSATT D. GRUTIN, Sup°t of Building LOCALITY r NEAREST FAR ANT TO FILL IN CROSS ST. LEGAL —� DESCRIPTION ALOT NO f _OWNER ^ r't; BLOCK TRACTa If: J i w f,. MAIL ADDRESS ✓_ ! _;, ✓..: NO.OF BLDGS. SIZE OF LOT NOW ON LOT i� CITY TEL NO USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY BK P6 CONTRACTOR a$ ADDRESS CONNECTION DATA CITY TEL,N0. STATION - DEPTH s_, STATE MANHOLE REFERENCE .^ REGISTRATION NO. ❑ COUNTY NO. I DESCRIPTION OF WORKFEE L LOWERS` HOUSE U3CS SEWERCONxECTING TO $3.00 TYPE OF CO�CF.L.TION LEM.L.TLNGTH FROM r SEPTIC TANK, SEEPAGE PIT OR Y. O P.L. PITS AND/OR OP,AINFIELD @ $3.00 UR OVERFLOW SEEPAGE PIT. DRAINFIELD EXT N.,CESS P00L,DRYWELL,MANH0LE 0 $2.00 HOUSE SEWER CONNECTING TO--� �j r, �# P.C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 C0.1 N0, r JOB NO. CONNECT ADDITfONAL BLDG.OR TRUNK PERMIT NO, ROAD PERMIT NO. WORK TO HOUSE SEWER @ $1.00 ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT,- a ` SEWER OR DISPOSAL SYSTEM a $1.00 PERMIT NO. — �~ INDUSTRIAL a WASTE APPROVAL CHARGES OWNER'S PERMIT S 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE 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— DAX OF ®y j q_v� NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENTS —------- OR WORK ADDRESS s x TSEPTIC TANK,SEEP,PIT(S) AND/OR GRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING TALT.ER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS Q SIGNATURE "`i SEEP.PIT(S) Q CESSPOOLS Q OF PERMITTEE �t v,AMATION ROBERT A.WOOD CK. Y.C. GLIFERVISING MECHANICAL ENGINEER WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self brr11 insure, or a certifir,;Ite ofrWkers'Compensation Insurance, or 76A642D Ll a certified copy thereof (Sec. 3800, Lab C.) CE BOB(REV B/Bt) APPLICATION FOR PERMIT Policy No. CompanyFr�til.-�v%Awx--_ ❑ Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL L� Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY departmen . DateApplicant _ FOR APPLICANT TO FILL 1N CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING f COMPENSATION INSURANCE ADDRESS k STATION A I DEPTH Y, (This section need not be completed if the work involved by the MANHOLE REFERENCE ! PPER permit is for one hundred dollars ($100)or less.) LOCALITY L WER NEAREST yy TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. �dl.Qct4, Z >ra Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner subject to the Workers'Compensation laws. P.C.NO. so as to become sub I p OWNER .�T F�;�S.'1i• 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. r. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Labor code, you must forthwith DESCRIPTION OT 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 y�^ effect. ((�� {+ CONTRACTOR 1 � L01-7/ -7 1 CONNECTION CHARGE FEE License Number 'W`r -Lic.Class_ L!� ADDRESS �y ` REIMBURSEMENT FEE O Contractor V 7'f 1`�, `t I Date y� DISTRICT NO. GROUP MAP PROCESSED BY V lF CITV _;, /\,�;G'V(;' TEL.NO. 65 s `. f �' `N ,r ( BK PG Z ❑ I am exempt under Sec. of the L.A.Co. srarE `/__ q! 7� O P LICENSE NO. - 7 tl' CLASS ` rb C �--� NO. DESCRIPTION OF WORK V Plumbing Code and/or Sec. of the FINAL HOUSE SEWER CONNECTING TO DATE ' VALIDATION "' B. 8 P. Code for the following reason k PUBLIC sew€R �A0 4�7 N SEPTIC TANK,SEEPAGE PIT OR FINAL PITS AND/OR DRAINFIELD , p� y � `S Yyts� Dale 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, Bulsness and Pro- ALTER,REPAIR OR ABANDON HOUSE fAI fessions Code): SEWER OR DISPOSAL SYSTEM ACCT rT i }n14' � El 1,as owner of the property,or my employees with wages as AY' i- 1 their sole compensation, will do the work and the structure 335,07 2 •--= is not intended or offered for sale (Section 7044, Business and Professions Code). OWNERS Permit $ 1TEMI, ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE VITA= 427 50 licensed contractors to construct the project Section 7044, TOTAL.` s` .� M P I ( I HAVE AT THIS DATE CONTRACT WITH THE HEREIN NAMED TRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CHECK1.% CONSTRUCTION LENDING AGENCY ^ I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF t. t1'bJ `�( OWNER OR for the c. 309 , Ci of the work for which this permit is t issued (Sec. 3097, Civ. C.). p OWNERS AGENT-- t �__' r _ - Lender's Name ADDRESS 1-G f0-0QC1 6,r2 18� Lender's Address u AM :3,4 1 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 upon th aboe, J n toned property for inspection purposes. Signature of Permittee ate SEE REVERSE FOR EXPLANATORY LANGUAGE