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Home My Public Portal About5271 SERENO DR_Sewer__ CE eDR IREv enol APPLICATION FOR PERMIT, m1 SEWER - SEWAGE DISPOSAL ` COUNTY OF LOS ANGELS BUILDING AND SAFETY FOR APPLICANT TO FILL IN DISTRICT Ro ..UF YM � �Pnogssco er EULLDWO ADDRESS .oY/ A/ M -7 Z� 1 ...J A/ LOCALITYC N ION DATA I ` NEI1NfiR STATION ' ` Dff T , CROEG ST MANHOLE REFER[NC[ , UPPER LOWER OWNER TYPE OF CONNECTION I- LENGTH FROM UPRNATROIZ��SYSTKM Y CURE PL METOPE RS PGNO 1� _ ✓ ' CO IMP NO JOG NO T[L AL �� TRUNRPERMITNO ROADFERMRNO IFT.ON LOT NO FIDAVRWAIVER EASEYERT RECORD INSTR NO DAT[ TRACT _ L —� 3�l NO OF BLDGS LOT �J E X 7� NOW ONLOT HWY OR ST WIDENINGNGS STAT[ENCROACHMENTACTORINOUBTRWASTE APPROVAL SS / CHARGESL NO ��/ CONNECTION CHA EE046 STATE E NO C CLASS c—� REWBURSEMENTFE[ DES I ION O RR FE[ APPROVALS DATE INSFBCTOR S SIGNATURE HOUSE SEWER CONNECTING TO PUBLJC SEWER SEITICTANR.8C8PAOE NEW ECTADOUSE EWER ITIO HT Soo/ORDRANNEI CONNECTAODRIONAL HRNAT SC W SR CONNECTING TO BUILDING OR WORE FRNATE DISPOSAL GYGT[M SEPTIC TANK BEEP FRlfl WORRtO HOUSE GEWER CONNECT ADORNDNAL ELDG OR AND/ORDRAINFIELD _ OVERFLOW SERFAGE FR DRAINFIELD CESSPOOL 0 DRYWELLO E%TN GE88PODL ORYWELL.YANHOl9 ALTER REFAJR OR ABANDON HOUSE ALTER R[ SEWER OR DI8F08AL SYSTEM FAIR HEWER OR SEWAO E DISPOSAL SYSTEM ' DI ONNSCTFLUp AND 1 ABANDON HOUSESCWER BACNFiLL S[PTR:TANI{SQ -� - OWNER'S ' Permit S SEEP PR(E)0 CESSPOOLS 0 I AUTHORIZATION-1 TOTAL FEE -�' VALIDATION NCT - 1 MAV[AT THIS DATE A CONTRACTM THE HEREIN D DDN .�4 2 6 3 A_ TRACTOR TO CONNECT THE ABOVE DE..RIMED CSISTINO OW BLLING TO"ff PUBLIC f[W[R 8 8 8 . 10 _ SIGNED TMISDAV OR T9_ OWMRS AGEHT NER OR 12 • 014.00 ADDRESS • • • 1 &005 I HEREBY ACRNOMILBDQE THAT I HAVE READ THIS APPIJGTMN AND STAT[THAT THE ABOVE IS CORRECT AND AGRa[TO COMPLY WRH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 0509-79 PLUMBI"AND SEWERS - 1 HER[[Y CERTIFY THAT I AM PROPERLY ROISTERED AND/OR UC[NS[D AS REQUIRED BY LOS ANGELES COUNTY AND STAT[OF LS ALIF011N IAORTHA AM THELEGALOM'NEROP ANDINTEHDTORE IDX W THE ASOV RIEED MSIDENTULL EERY I IGNATURE - OF PERMITTEE L TEA EAZD-CEI-10-T1 APPLICATION FOR PERMIT .'�_'COUNTY OF LOB ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING D G 5271 Sereno Dr. ALITY Te Ci APPLICANT TO F LL IN REST f9 ST [DL78CRI�IMOT NO NER Phil ROckenback _ 10128 Rash Street RACT RESS O OR YLDOY E NOnte NOWONLOT CITY I' L 1l'lRl!! VV OO TCL NO (� � DICTRICTNO [ROUPMAR ;D BY CONTRACTOR Oren Bros, P1 L D BE R9 RR C 6 M- ADDRESS4265 N. Baldwin Ave, CONNECTION DATA CITY El Monte TEL NO (WaSTATION I� /_ AGi DEPTH STAT[ 2M 7 )wp�yVpp C^[/��]C �10 MANHOLE R[F[R[NC[••+ �V v yam. L IC[HSE NO 2 ` alOC�ii1p .C36-2 NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEND FROM HOUSE SEWER CONNECTING TO Y CURB M L TO P L PUBLIC SEWER 0 fT 00 SEPTIC TANK SEEPAGE PIT OR J C NO PITS AND/OR ORAINFI[LO 0 BID GO CO IMP NO JOB NO HOUSE ECWCR CONNECTING TO TRUNK PERMIT XO ROAD PCRMR NO d PRIVATE DISPOSAL SYSTEM 0 []00 CONNECT ADDITIONAL BLDG OR AFFIDAVIT RAID. AA.ASAYY RECORD INSTR NO O DATI 0 WORK TO HOUSE SEWER 0 []00 OVERFLOW SEEPAGE PIT DRAINFIELD W 9XTN CESSPOOL DRYW[LL 0 ES pO O ALTER REPAIR OR ABANDON HOUSE HWY OR.T WIDENING Lam, SEWER OR DISPOSAL SYSTEM 0 $300 STATE ENCROACHMENT MANHOLE 0 $T 00 PERMIT NO d INDUSTRIAL �j. 0T WASTE ARRROV �Z /i!J Z OWNER'S PERMITs E 00 AUTHORIZATION TOTAL FEE D CONNECTION ROE FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F!! TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER DAT[ INSPCCTO SIGNATURE SIGNED THIS DAY OF 18_ OWNER OR NEW HOUSE SEWER OW NCR6 AGENT CONNECT ADDITIONAL ADDRESS BUILDING OR WORK 6[PTIC TANK SEEP PlTlil I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAINFIELD AND STAT[ THAT THE ABOVE 15 CORRECT AND AGR[[ TO COMPLY WITH ALL COUNTY 0ROINANCCS AND STAT[ LAWS REGULATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWCLL ❑ 1 HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR S[W[R OR LICCNSLD AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR TX I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE SCRIBED R NTIAL PROPERTY ABANDON HOUSE BEWER 61GNATUR[ BACKPI LL BE, TANKS ❑ OF PLRMTTT[C SEEP PITIS) parmsrQOL.s VALIDATION CX M CASK 1 T 0 0 9 �Tov 2!5 D 1 0.0 D e e • WORKERS'COMPENSATION DECLARATION Gl t4'b".by"Miirm that I hove a certificate of consent to self ILII ,Insure or a certificate of Workers Compensation Insurance or F^A� a certified copy thyreof(Sec 3800, Lab C ) a"(REV APPLICATION FOR PERMIT Policy Nval/ �Compony (7 ,a ms 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 Date Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS MIMING _ COMPENSATION INSURANCE ADDRESS sTATRDN DEPTH (Thu section need not be completed if the work involved by the ' LOG^dITY MANHOLE REPTRENCE L-5W UPPER permit t;for one hundred dollars ($100)or less ) A I certify that in the performance of the work for which this CREARE sr TM��c�NECDON TME permit Is issued I shall not employ any person In any manner Y cuRB P t M L TOP t so as to become subject to the Workers Compensation Laws P c No Pe OWNER CO IMP NO JOB NJO kA TRUNK PERMIT NO ROAD PERMIT NO Date Applicant S NOTICE TO APPLICANT If after making this Certificate of TEL NO AESIDAVIT WAIVER EASEMEM RECORD INSTR NO DATE Exemption you should become subject to the Workers Compensation provisions of the Labor code,you must forthwith LEGAL LOT No Hwr OR si NROErvIIVG comply with such provisions or this permit shall be deemed revoked TRACT STATE ENCROACHOVENT NO OF SLOGS PERMIT NO LICENSED CONTRACTORS derDECprovisions LOT Now ON LOT I hereby affirm that I am licensed under provisioru of Chapter 9 (commencing with Section 7000) of Division 3 of the Busl Gs otARGEs ness and Professions Code and my license Is In full force and IF effect ACTOR CONNECTION CHARGE FEE y License Number .7,6 �� Lic Class ef V Z S REIMBU45FMENT rzE O CDntracton4ea Date /O�Z — .�'d' LrEt No DISTRICT ra GROUP MAP DBY ZBK PGIom exempt underSec of theL A Co NO CL« G 1Plumbing Code and/or Sec ofthe NO HJUSESE RRCONNOF WORK HNA TALIDATI GIgl/5f SEWER PTIONEO F W R DATE C{B 8 P Code for the following reasonPFK TANK SEEPAGE Pn GRFINAL/a !-7 Date /D /3 $ WFS ANID/OR DRAINFIELD BY �� PRIVATE P15P CONNECTING TO Signature CONNECT ADDITIONAL BLDG M OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERROw PAGE%i DEAINFIEID OIL hereby affirm that am exempt from the Contractor's license ExTN CESSPOOL DRvwEu MANHOLE 0 9 0,4 A Law for the following reason (Sectors 7031 5, Bulginess and Pro- ALTER REPAIR OR ABANDON HOUSF fessions Code) SEWER OR DISPOSAL SYSTEM # 9'e's e 1 0 ❑ I as owner of the property,or my employees with wages as I their sole compensation wJll do the work and the structure g g Is not intended or offered for sale (Section 7041 Business and Professions Code) OWNER'S Permit i ❑ 1,as owner of the property am exclusively contracting with JAUTHORIZATION TOTAL FEE licensed contractors 10 COn]hUat the project (SBCfIOn 70411 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTI TO Business and Professions Code) CONNECT THE ABOVE DESCRIBED EXISTING DWEUING TO THE PUELK SEWER CONSTRUCTION LENDING AGENCY , I hereby affirm that there Is a construction lending agency SIGNED THIS DAYOF 19_ for the performance of the work for which this permit is OWNER OR ' issued (Sec 9097, CIV C ) OWNERS AGSMADDRESS Lender s Name Lenders Address I certify that 1 have rood 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-mention property for Inspection purposes 4�:gee.) A /o - /z _ if S, Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE