HomeMy Public PortalAbout5116 A & B SERENO DR_Sewer__ 76 42-D '
U RE ° B' APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY 7
FOR APPLICANT TO FILL IN oIs Rlcr No cRouP "P IPIIOCESSED BY
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I NAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON -
TA TM60�:0 CONNECT THE ABOVE DESCRIBED EXISTING DWEWN6 @394.7A
SIGNE13THIS DAY OF 1Q_ tt • • E E , O
OWNER OR
OWNERS AO[M
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ABOVE IS COMER ANDDAGRI Q TO COMPLY APP�CATIONrf E E 210,05
WRH ALL COUNTY OROINANCQS AND STATE LAWS REGULATING
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I HEREBY CERTIFY THAT 1 AM PROPERLY
REGISTERED AND/OR
LICENSED AS REWIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO RE _
SON IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY
SIGNATURE '
of PCRMrrne
75" "Z°` `E°°°� °"' APPLIC ION FOR PE MITsIao
COUNTY OF LOS ANGELES SEWER—SEW ISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION EUILDIwG A
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DESCRIPTION LOT NO [/ OWNER
I MAIL
BLOCK TRACT ADDR[[p
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SIZE Or LOT NOW ON LOT CITY � TEL NO
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NO DESC PT ON O W RK FEE TYPE Or CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURE P L MIL TOP L
PUBLIC SEWER Q $700 PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD (1000 CO IMP NO JOB NO
HOUSE S[W[A COMNCCTI NG TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 0 q 00
CONNECT ADDITIONAL SLDO OR AFFIDAVIT RMEE• W.... RECORD INSTR NO DAT[
WORK TO HOUSE 5SW[R O 5300
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ERBSPOOL ORYW[LL OUSE O Sam HWY OR ST WIDENING ` U
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ADTHOFIZATION TOTAL FEE CONNECTION CHARGE F[[
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F[[ /
"ACTOR TO CONNECT THE ABOVE DESCRIBED A �VA�
TO THE PUBLIC SEWER DA INS TO 0SIONATUR
SIGNED THIS DAY DF 19_
OWNER OR _ NNW HOUSE E[W[N
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEER PIT(S)
1 HEREBY THAT
THE DGEABO THAT I HAVE ROAD THIS ATO COMP
Y AND/OR GRAINFIELD
AND STAT[ THAT TH6 DIVA IE CORRECT AND AOR[[ E LATING
WITH G COUNTY ORDINANCES AND STATE LAWS REGULATING
PLV IXO AND SEWERS CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT 1 AM P ERLY R IST[RED AND/OR ALTER REPAIR SEWER OR
L [NEED AS REQUIRED BY LOS OLE DUN Y AND STATE OF SEWAGE DISPOSAL SYSTEM
LIF(y1 NIA OR THAT IAM THE O WNER ANO INTEND TO DISCONNECT PLUG AND
BI VE D IS D [BID[NTI PROPERTY ABANDON HOUSE SEWER
PLEMMEE L FILL SEPT p ❑
BEEF PITI$I ❑ CESSPOOLS
VALIDATION CK M o err
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