HomeMy Public PortalAbout5048 SERENO DR_Sewer__ 8&Haas its" APPLICATION FOR PERMIT 1
DIVISION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Enptnm
County of Loa An"i" ADDRESS " $`r
JOHN A LAMBIE COUNTY ENGINEER
m CASSATT 0 GRIFFIN SUP T OF BUILDING LOCALITY r�eiM� PIP
FOR APPLICANT TO FILL IN CR093 NEAREST
LEGAL I MAIL
A,
DESCRIPTION LOT NO70' OWNER
BLOCK TRACT ADDS ESS rip y8NO I SIZE OF LOT NOW OONBLOT S y
/ CITY /-/��� C TEL NO
USE OF DISTRICT NO GROUP + YAP
USE OF ,
�� peal BK PG
CONTRACTORS'
ADDRESS ,_, M CONNECTION DATA
CITY ej TEL NO �Q B�-�O�Q STATION 1 J f� . DEPTH
MANHOLE REFERENCE J;,<
_ �J UPPER
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM
I PUBLICSEWER�CON NECTING TO UR
@ f! SO ,4r Y P L Y L TO P L '
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD ® f 3-200-
OVERFLOW
0OVERFLOW SEEPAGE PIT GRAINFIELD P C NO '
EXTN CESSPOOL DRYWELL MANHOLE f 2 00 CO Iup NO JOB NO
H OUSE SEWER CONNECTING TO J q
PRIVATE DISPOSAL SYSTEM @ f 1 00 TRUNK PERMIT NO ROAD PERU IT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ f 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® S 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWI'IER'S PERMIT S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN XAUED CON.
APPROVALS GATE IPSP CTOR 9916NATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEN HOUSE SEWER Z S
t
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWNFA. OR �p��. . Ire .� �^�A-� BUILDING OR WORK
OWNERS AGENT/Y I --- SEPTIC TANK SEEP,PIT(S)
ADDRESS AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL(:] DRYWELL❑
AND !TATE 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR AND
O
LICENSED AS REQUIRED BY LOS ANGELS! COUNTY AND STATE OF ABANDON DISCONNECT CT PLUGHOUSE
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE '
ER
DESCRIBED RESIDENTIAL PROPERTY BACKFILLSEPTIC TANKS
SIGNATURE
SEEP PIT S) E) CFSSp0OjS
OF PERM ITTEE� �-
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR '
1�2 8 9 9A � M4 uFN 450 tD
WORKERS COMPEt15T10 DECIARATIOt�I
I hereby affirm that I hovel a certificate of consent n sell - }}
Insure oro certificate o4,Worken'Eompenwtto imur6nee, m `•J61bm U
a certified copy thereof(Sec 38DO Lab C ) t CEMPIFv I/0I APPLICATION FOR PERMIT
Policy No company SEWER - SEWAGE DISPOSAL
El Certified copy s hereby fumuhed
❑ Certified copy is filed with the county building Inspection I COUNTY OF LOS ANGELES BUILDING AND SAFETY
dopa er�7 L
Date / Applicant ` FOR APPLICANT TO FILL IN CONNECTION DATA
IFICATE OF OMPENSAETION IINSURANCEPTION FROM ORKERS' ADA D�Dlss o 8, O Zq'e STATION /A+011,2, DEPTH
(This section need not be completed If the work Involved by the I LOCuITYly P —HOLE REFERENCE 2 T Q s 8 S.
permit Is for one hundred dollars ($100)or less ) 1044,
H FRCW�
I certify that In the performance of the work for which this ( CROSS;ST r TYPE OF PL ML TOPLL
permit is Issued I shall not employ any person In any manner NO
so as to become subject to the Workers Compensation Laws OWNER a P x lvG U/� wNo �s .1oe I
'
Dote-Applicant Ap:, 14-41W '- TRUNK MRABT NO' ROAD PERAVT NO
NOTICE TO APPLICANT If otter makingthis Certificate of AsrIDAviT WAIVER EABEWNT RECORD INSTR NO DATE
CITY TEL No /r- 3d8-
Exemption you should become subject to the Workers' LEGAL
Compensation provisions of the Labor code you must forthwith DExRIMION for No IrA'r MST WTDENNG
comply with such provisions or this permit shall be deemed
revoked BLOCK TRACT STATE DICROACHIVENT
NO
LICENSED CONTRACTORS DECLARATION NO a UDG
PE4
OF Lor
sizE LOT Now ON
AVT
I hereby affirm that I am licensed under provisions of Chapter M OF
9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES
ness and Professions Code and my license Is In full force and // �
effect ' CONTRACTOR o llazv n L!/ IDN CK�'E
HE As
4Cense Number LIC Class ADDRESS 3//. /OZC7 V REIMBURSEMENT FEE
E� QQ' / / A.
Con octw Date CITY (Oe- S Tr Ste- .rte � b DISTRICT No (�iRWP AUI PROCESSED er O
s r /�7�Ly ox
PG V
❑ I am exempt under Sec of the L A CoJAUTHORIZATION
rq U ij(,! LIC C'.-3{i �L tJ D R M
K
DESCRIPTION OF WORK FFE
Plumbing Code and/or Sec of the DATE o
SE SEWER CONNECTING i0 ^� DAIS VALIDATI �l
B 8 P Coda for the following remon SEPTIC R
rANc SEEPAGEPit
oR nNu
RT$AND/OR MAINFI LD y5
Data HCU',IE SEWER CONNECTING To er �• 7C
PRIVATE Signature CONNECT ADOITIONAI BLDG OROWNER-BUILDER DECLARATION WORK TO 110113E SEWER
NFIELD
I hereby affirm that I am exempt from the Contractw s License � LCESSPOOL DRVWEIOW SEEPAGE PIT LIAIiAANHOLE
Low for the following reason (Secton 7031 5 Busness and ProALTER REPAIR OR ABANDCN HOUSE 8 1 19 1 A
fessions Code) SEMEN OR T115POSAL SYSTEM❑ I as owner of the Property or my employees with wages asIee ,Z75O
their sole compensation, will do the work and the structure Is not intended or offered for sale (Section 7044 Businessand Professions Code) OWNER'S Permit f e e e 27Jr0FE❑ I as owner of the property,am exclusively contracting with TOTAL FEE
hfensed COOMOCton to construct the project (Section 7044 VE AT THIS DATE A CONTRACT WITH THE HEREIN NANED CONI oR TO 1207-84
Business and Rofessions Code) NECr THE ABOVE DFSOIIBED E%45TING DWELLING TO TIE PUNIC SEWER
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is a construction lending agencyED THIS DAY OF 19_for the performance of the work for which this permit IsR OR
issued (Sec 3D97, Civ C ) OWNERS AGENT
IN
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 jaws regulating Plumbing and Sewers,
and hereby authorize representatives of this County to enter /
upon the aabove-m/enJtiAo'nn property for inspection purposes
Signature of Ps nee Dbte - _- M Rr4nU FOR EXPLANATORY LANGUAGE