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Home My Public Portal About6152 ROSEMEAD BLVD_Sewer__ °AE{ ° 6•BFi3 12-34 APPLICATION FOR PERMITS& . DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL Department of County Engineer County of Los Angeles 3UILDiNG � V.'M.J. FOX, COUNTY ENGINEER ADDRESS �Z CASSATT D. GRIFFIN, SUPT OF SUILDINc �'_CCALiTY +i f FOR APPLICANT 4'O FILL IN NEAREST LEGAL '. ' DESCRIPTiON___ LOT N0. " BLOCK: V TRACT N1,AIL : - `� 3 k•w E .✓ NO.OE SLDGS. ADDRESSSIZE OF LOTp` NOW._.ON LOT CITY TEL, NO. USE OF �. �-; -- BUILDINGS DISTRICT NO. + GROUP MAP - --`.�' BK.. PG 9 -..�' CONTRACTOR - y,„ ,y.. ,Iy I z c ADDRESS '� � -' �..,�-"_ � � _ CONNECTION DATA CITY TEL.N O. - +' r -- STATION +� DEPTH STATE .,-- LANHOLE REFERENCE REGISTRATIO NO. s'f [I COUNTY . $�v' �, UPPER Y - TYPE O NNECT LENGTH FROM •" NO. DESCRIPTION OF WORK FEE P.L. HD USE SEW�R CUhNECTSNG TO PUBLIC SEVERt±_$ 3.50-HOUSE.SE. SEWER CONNECTING'TO _ PkIV_AT_F DISPOSAL SYSTEM_ _ 1.00 -- - -- ----- CONNECII ADDITIONAL BLDG. OR V ;0, - J ORb:TO HOUSE SEWER 1.00 i� OB. N0.IMP. NO,----___ :� �.I .' ALTER DR RFQAiR X ST1Nv 1 S WEP. OR u S"--OSA_SYST E_M 1.00 ` i TRUNK PERMIT NO, ROAD PERMi7 DiSCONNE s AND ABANDON 'SEW'ER AND/CR DISPOSAL SYSTEM .TATS' ENCROACHMENTf 00 �^ i— � f SEPTICTANK,SEEPAGEPIT_OR_ __ �. PITS AND OR . RA r FIELD! 2,00 iNDJSTRIA.L CESSPOOL DRYYYELL -_.. WASTE APPROVAL CORDITiON- ONLY _Oh CHARGES •,y"�� -� CONNFCTION CHARGE FEE OWNER'S PERMIT _i ' 00 -- AUTHORIZATION LTOTAL FEE d y r8 RF MBURSEh1ENT PEE 1 HAVE THIS DATE CONTRACTE=D WITH THE HEREIN NAA'.ED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLIM1 APPRO is DATE INSPECTORS SIG-NATURE TO THE PUBLIC SEINER _ — _ --- -- --- Y NEW HOUSE SE`lIER SIGNED'�"I-I15�.a__.DAY OF_ t=¢�"""'�'I 15 _�_ OWNER OR CONNECT ADDITIONAL OWNERS AGENT '. '`?'_,� _'z,,.: .)' BU1+DING OR V..`ORK SEPTIC TANK.SEEP,.PIT($) P,QGF E:fi�_�-_ --__ _.-.._,..e._ _40,!D,'O_R DRAT FIELD ,,.`....._. I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CE:SSPOOL[VDRYWELL 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 CER" R iF THAT I AMPROPERLY REGISTERED AND/OP LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STA: E OF DISCONNECT PLUG AND CALIFORNIA OR THAT. I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER - pES,RIBEDRESICENTIA4 PROPERTY ?' BACKFILL SEPTIC TANKS[3 JJ .a W a.EP. PIT(S) C} CESSPOOLS 0 OF PERMITTEE' WILLIAM J.FOX, owns ENGINEER VAMDATION n1 BT BY _. DEPUTY DEPUTY ,2 BY BY DEPUTY DEPUTY WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof(Sec. 3800,,,Lab C.) 92.00)2DPW 6,88 APPLICATION FOR PERMIT Policy,No. Company F !M � � : , I T [],Certified copy is hereby furnished. SEWER - SEWAGE DISPOSAL "O Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment. Date "fApplicant F, FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING COMPENSATION INSURANCE ADDREss , -- '_ . sTAnON DEPTH (This section need not be completed if the work involved by the `4 r MANHOLE REFERENCE UPPER OWER permit is for one hundred dollars ($100)or less.) LOCALITY I certifythat in The performance of the work for which this NEAREST �L p A TYPE OF CONNECTION LENGTH FROM P CROSS ST, '.- Y. CURB P.L. M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. _ I PC.NO. OWNER � '� CO-IMP.NO. JOB NO MAILr/ ��`` C. TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDPES$ A �..�'F. NOTICE TO APPLICANT: If, after makingthis Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD INSTR.NO DATE CITY TEL.NO. 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- BUUDwGs 4, - CHARGES and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE . � _ �G� License Number "„`--LIC.CIOSS ADDRESS r•1 �”` _ jv .� - .:y REIMBURSEMENT FEE Cor'ractor, rJa1e - DISTRICT NO. GROUP MAP PROCESSED BY z CITY C TEL.NO.d 4.r -��sj c, BK PG -> 0 I am exempt under Sec. of the L.A.Co. STATELICENSE No. Fj( r. t1C. I Plumbing Cade and/or Sec. NO. DESCRIPTION OF WORK FEE a W of the �yFINAL VALIDATION V) �,. PUBLIC C SEWER DATE CONNECTING TO S B. 6 F. .wode for the following reason SEPTIC TANK,SEEPAGE PIT OR Z PITS AND/OR DRAINFIELD FINAL y Date HOUSE SEWER CONNECTING TO BY {^' PRIVATE DISPOSAL SYSTEM Signatur8 CONNECT ADDITIONAL BLDG.OR , OWNER-9UILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT,DRAINFIELD I hlpreby affirm that I am exempt from the Contractor's License EXTN„CESSPOOL,DRYWELL,MANHOLE L for the following reason (Secton 7031.5, BUisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE feS$IOnS Code): SEW:R OR DISPOSAL SYSTEM - 1,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure AS not intended or offered for sale (Section 7044, Business $ Permit and Professions Code). OWNER'S ❑ 1,as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, 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 AGENCYn; I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF_Gi 19 for the OWNER OR ti performance of the work for which this permit is OWNERS AGOfiMT issued (Sec. 3097, Civ. C.). C� -- ADDRESS - Lender's Name Lender's Address 1 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 the above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76A6420 alacycertified opy r o (Sec. 3800, La ,, sa-0002DPW s.se APPLICATION FOR PERMIT Policy.No el� Companyff!! (, ❑ 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 Doti" C Applicant_�d� 1' li, FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' STATION DEPTH COMPENSATION INSURANCE A DDRESS ,^ yf- - J (This section need not be completed if the work involved by the MANHOLE REFERENCE UPPER permit is for one hundred dollars ($100)or less.) EA LITY v LOWER certify that In the performance Of the Work for Which This SNEARESST, ,.. TYPE OF CONNECTION LENGTH FROM Y. CURB P.L. M,I.TO P.L. permit is issued, I shall not employ any person in any manner P.C.NO. so as to become subject to the Workers' Compensation Laws. ER t ~ CO IMP.NO. JOB NO. P ; d TRUNK PERMIT NO. ROAD PERMIT NO. Date. Applicant ESS ; sirNOTICE TO APPLICANT: If, after making this Certificate Of AFFIDAVIT WAIVER EASEMENT RECORD.iNSTR.NO.TEL NO.Exemption, you should become subject to the Workers' GAL Compensation provisions of the Labor code, you must forthwith IPTION LOT NO. HWY.OR ST.WIDENING comply with such provisions or this permit shall be deemed revoked. BLOCK TRACT STATE ENCROACHMENT . LICENSED CONTRACTORS DECLARATION NOOF BLDGS. PERMIT NO.Si2E 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 r effect. CONTRACTOR TLA__ CONNECTION CHARGE FEE License Number ��4�y.d Llc.Class �'� ADDRESS � 'e r..l,��'i`� s. C'� REIMBURSEMENL FEE Contractor b-T' �' —Date _C� R DISTRICT NO. GROUP MAP PROCESSE6 BY O ' CITY TEL NO. - ❑ I am exempt under Sec. �of the L.A.Co. STATE { LIC. V �/y BK Pc LICENSE NO. e .*`� � _• CLASS 3�.., Plumbing Code and/or Sec. of the NO. DESCRIPTION Of WORK FEE FINAL HOUSE SEWER CONNECTING TODATE ,,, VALIDATION to B. &P. Code for the following reason PUBLIC SEWER ,/ _E z SEPTIC TANK,SEEPAGE PIT OR FINAL AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY Signature t� "� - ` PRIVATE DISPOSAL SYSTEM i g CONNECT ADDITIONAL BLDG.OR ,A 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 not intended or offered for sole (Section 7044, Business nd Professions Code). OWNER'S Permit $ as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FEE ' icensed contractors to construct the project (Section 7044, i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO usiness and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY ► I eby 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 - Lehder'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, a , and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE WORKERS'COMPENSATION DECLARATION .I hereby affirm that I have a certificate of consent to self insure, or a certificate of Workers'Compensation Insurance, or 76n6421) a certified eppy t reorf(Sec. 38010, L46 82-4002 DPW 6/88 ) a - r, APPLICATION FOR PERMIT Policy•Nc Company. ❑ 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.— It Date _ -___. 6'Applicant �' At le",C FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS' BUILDING Ym t ; STATION DEPTH COMPENSATION INSURANCE ADDRESS ' ' F€; t`► ) (This section need not be completed if the work involved by theIOCAItTY /I�i ' �_� ( MANHOLE REFERENCE UPPER OWER permit Is for One hundred dollars ($LOO) Or LESS.) NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS Sr. ;h' Ind Y. CURB P.L. M.L.TO P.l, permit is issued, I shall not employ any person in any manner p� �j so as to became subject to the Workers' Compensation Laws. OWNER �. A V` Y e-1 CO.IMP.NO. JOB No. MAIL - f•'�rw `'.. TRUNK PERMIT NO, ROAD PERMIT NO. Date Applicant ADDRESS t�4. f NOTICE TO APPLICANT: if, after makingthis Certificate of T y C AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE CITY � TEL NO. .^+^s"�/ 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 517F OF O? NO.OF BLDGS. PERMIT NO. L I hereby affirm that I am licensed under provisions of Chapter NOW ON LOT USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BIPLDINGs ;' , ( t a' CHARGES ness and Professions Code, and my license is in full force and fc�y effect. . . CONTRACTOR F , -""fit CONNECTION CHARGE FEE License Number LIc.Class r2 REIMBURSEMENT FEE ADDRESS l~ '"� i .. ";F _ DISTRICT NO. GROUP MAP PROCESSED BY Cor?ractar C �L' 1. 7! Date `;I- CITY S P TEL.NO. .,N i ��,- C� 0 ( STATE . LIC. ' ,�''",�; BK PG - ❑ I am exempt under Sec. of the L.A.Co. LICENSE NO. y �o ) `•� - �� y " F CLASS a�',� G✓ G NO. DES RIPTION OF WORK FEE W Plumbing Code and/or Sec. of the FINAL r" n PUBLIC SEWER SEWER CONNECTING TO DATE 6,,s`>„ . ',� VALIDATION B. & P. Cade for the following reason SEPTIC TANK,SEEPAGE PIT OR FINAL,- PITS AND/OR DRAINFIELD _ --. Date _ BY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM Signature_ i_ tt.6 _�T+ P 'F \' CONNECT ADDITIONAL BLDG.OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER he=eby affirm that I am exempt from the Contractor's license NRELD I OVERFLOW CESSPOOL,DRYWELRL,4IMANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAOR ABANDON HOUSE foissions Code): SEWER OR DISIR POSAL SYSTEM LJ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure it not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ 1, 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 CONTRACTOR TO j Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. - CONSTRUCTION LENDING AGENCY I phereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19OR ` fmrx,the performance of the work for which this permit is OWNER Is3tied (Sec. 3097, Civ. C.). OWNERS AGENT - ADDRESS Lender's Name Lender's Address cer'ify that I have read this application and state that the above=information is correct. I agree to comply with all County ordincnces and State laws regulating Plumbing and Sewers, and nereby authorize representatives of this County to enter Upon the above-mentioned property for inspection purposes. 5icU nature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE