HomeMy Public PortalAbout6320 SALTER AVE_Sewer__ 8858211 APPLICATION FOR PERMIT
8'59
E805
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
IOHN A. LAM M, County Enainee: ADDRESS
CASSATT D. GYIIFFIN, Su t o1 Building 4 LOCALITYNEAREST
p�
FOR APPLICANT TO PILI. IN
CROSS ST. x ej u_
LEGAL ,
DESCRIPTION LOT NO _ `"3 +'r� C , OWNER
BLOCK TRACT MAIL
ADDRESS
NO.OF BLDGS. r' 3
SIZE OF LOT NOW ON LOT CITY `�°! TEL. NO. Z Z
USE 0! DISTRICT N0. GROUP MAP PROCESSED BY
BUILDINGS ' '' L ICT GROUP 8% PG
CONTRACTOR Y v" -
ADDRESS CONNECTION DATA `
CITY TEL.NO. STATION - DEPTH
❑ STATE MANHOLE REFERENCE 1PPER `
REGISTRATION N0. ❑ COUNTY 9' -` --v- LpyyEP
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER C--3 $3.00 TYPE OF CYNfiECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00 y
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN..,CESSPOOL, DRYWELL @ $2.00
HDUSE SEWER CONNECTING TO F .' P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0, I06 N0.
CONNECT ADDITIONAL BLDG.OR 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
owNEF s PERMIT $ 2100 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
DATE A CONTRACT WITH THE HEREINAMED CN-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF I9_ NEW HOUSE SE%
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
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,REPAlR,SEWEROR
PLUMBING AND SEWERS. SEWAGE REPAIR,
DISPOSSEWER EM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM HE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL 7Y a f'-i EACKFfLL SEPTIC TANKS ❑ El
SIGNATURE SEEP.PITS ❑ CESSPOOLS
OF PERMLTTf
VALIDATION y ROBERT A. wood
CIL U.p, CASH SUPERVISING MECHANICAL ENGINEER
4 2zs
WORKERS' COMPENSATION DECLARATION 20 0051 GPw 6189
i hereby affirm that I have U Certificate of consent to self L` k!
Insure, or a certificate of Workers' Compensatan Insurance, o
! 76P.542G
o certified copy thereof (Sec, 3800--'-gfa..0 ',.f� APPLICATION FOR PERMIT
Policy No..__--__ Ccmrar.y__.��/
i Certified cony is hereby furnished SEWER - SEWAGE DISPOSAL
1 Certified copy is filed with Jb,,dunty buildingIns ,_e<r COUNTY OF LOS ANGELES BUILDING AND SAFETY
df EI
Date _ Applicant -11x :e^ ? ij3 FOR APPLICANT TO FILL IN CONNECTION DATA
CERTIFICATE OF EXEMPTIO ON WORKERS' ulc ctNu f ) t Cf C STATION r DEPTH
COMPENSATION INSURANCE Arxrr3Es: f(% LJ ''
;This section need not be completed if the work involved by the - MArNHOLE REFERENCE
it F
permis for one hundred dollars 41001 Or less,i LOCALITY <•' X.; _ C...;-._ ( �.-�, LOWER
NEAREST r b.. TFrE OF.CONNE-TION LEN
GTH FROM
I certify that in the performance of the work for which this CROSS 8 e-r. L,,(:P e}.. e':-a if i.I '�"".C,' y CURB P L ML TO,P L
permit is Issued, I shall not employ any person in any manner LEGAL
p C N
so as to become suktlecr to the Workers'Compensation Laws.- DESCRIPTION LOT Na
CO ftG' NG JOB NO
BLOCK, TRACT TkUNr PERMIT NO ROAD PERMIT NO
Dale -----.App!lcont --
NOTICE TO APPLICANT If, after maklnq this CertificateMAP of A PSSCRBOOK AFFrD.AVIt WAu{R EnSeMENr RE 3RD IVSTR NO DATE
63O H. PAGE RAHCFi _
Exemption, you should become subjeet to the Workers' NO OF E'LDG5. + —
Compensation provisions of the Labor code, you must forthwith SIZE OF LOT NON:ON LOT
Hwv OR ST WIDENING
comply with such provisions or this perrnir shall be deemed USE OF —
revoked. P.UILDINGS STATE ENCROACHMFNT� -
PERMIT NO
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter cwvE
9 (commencln with Seoton 7WO0 of Division 3 of the Busi- MAH_ -
g +.... .i(, .
Hess and Professions Code, and my license Is in full force and ADDRESS, )r-�.,t CHAPGfS
effect. GITY TEE NO �7 's'"t `c.y t� 2)6 CONNICTt'JN CHARGE FEE
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License NufrfG@r T> /(, _' lass I S} vE 9URSC MENT FEE
f
CON fR r Il rt t. /a t"�6 d �fw�.: 6` a l �`� M
Contractor_
a 'J #' { 6 "�. DfStRICT r 0 GROtip MAP PROCESSED BY
ADDRESS ... { ;. ` e��..,. + Cr'� 1 �..
❑ I am ezem t under Sec___. of?he L.A. Co. ) C i' `� � ' ✓°yy XV�a
esu,Pill, °- ,rf�!3
PlumbingCode and Sec, of the TATE ,� 1 v L,
�.— ('' r � NAI
E r:ENSE Nc�. .�� - s- ,,., cE-Ass 5�..-~-d-.. '` DATE l VALIDATION z
B & P. Code for the following reasr_. _ NO. DESCRIPTION OF WORK FEE 6 c (.• 0
HCUSE''AWER 'ONNE_ iNG TC rLNAi
DateELIC SEWER BY
d:2�._— SEFT.0 TANK SEEPAGE PIT OR LU
II
Signature _�.^__�. At', OR DRAINF F D 0)
OWNER-BUILDER DECLARATION HOUSE SUMER CONNECTiNG TO - � z
PRIVATE DISPOSAL SYSTEM
I hereby affirm that I am exempt from tr,e Contractor's License C,DNNFCT ADD ONA BLDG OR
Law for the following reason 'Secion 7031 5, Buisness and Pro- _ `AORK TO HOI.,SF SEWER _ ds
feSstpr,s Code): r ERr OW SEEPAGE PIT .RAINFE[D
kr CESSPty i.DRYWELL MANN..^-,LE
r l l ALTER REPA R 0R'ABANDON HOI,SE
as owner of the property, or my employees with wages as �1a_R.`R S✓r`SAL SYSTEM / G' 7171-
Their
their sole compensation, will do the work and the structure
is not intended or offered for sole (section 7044, BusinessTT
_
and Professions Code). u L Q
1 I, as owner of the property, am exclusively contro-ting with Permit $
licensed contractors to .onstruct the project (Section 7044. OWNER'S __ _
0k if,
Business cold Professions Code;. AUTHORIZATION TOTAL FEE
CONSTRUCTION LENDING AGENCY I HAVE AT THIS ,ATE A rONTRACT WITH THf, HEREIN NAME NTRACTO< r,. rl*, P"the
hereby affirm that !here is a Construction lending agency >r)Nr E� HF/.B vE vEscR 6E Fk:Isr�Nc, NE.LiNC.10 n f P a. SEWER
for the performance of tale work for which this pe..mlt I<
Issued (Sec, 3097, CGv, C SIGNE[)THIS DAY()F _I _
i)WNER OR -!!
Lender's Name----,---------_-- -- JVJNERSAC,rNr _--- -----
AD;KESS
Lender's Address _._
I certify that I have read this application and state that the
above information is Correct. I agree to _ompiy with all County
ordinances and State laws regulating Plumbing and Sewers,
and hereby authorize representotives (�f this County to enter
uparyt4Te gb� e-men*oned pscnerry f r inspection purposes,
r
Slgnafof Permittee - - SEE REVERSE FOR EXPLANATORY LANGUAGE
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