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Home My Public Portal About5702-5704 SULTANA AVE_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1 DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION COUNTY OF LOS ANGELES WILLIAM J. FOX, COUNTY ENGINEER BUILDING CASSATT D. GRIFFIN, SUPT or BUILDING ADDRESS FOR APPLICANT TO FILL IN LOCALITY ADDRESS - ' ,..NEAREST _ _ .Cff()SS ST. LOCALITY r �,'` DISTRICT NO. SERIAL NO. j PERMIT NO. Al tv*AA NEAREST A I S CROSS ST. %f' RECEIVED BY Ready for Inspection �— DATE ISSUED OWNER o �" MAIL �& z USE ZONE OCCUPANCY MAP rt ADDRESS -� '. �,��„ � _ BK PG CITY-1]p r TEL t � - CONTRACTOR ;- CHARGES REIMBURSEMENT FEE ADDRESS REQUIRED :N&-r REQUIRED � ' ,� .NO :. �..-- CITY .— I � CONNECTION CHARGE FEE REGISTRATION ?1iD } ` STATE rGO.IMP.NO- - 74UNTY LEGAL RECEIPT NO. DATE BY � �- DESCRIPTION LOT NO. BLOCK ' -TRACT��—�� # �— ,�., g r WAIVER FOR RECORDING LOT/ NO.OF AeDGS. SIZE OF LOT f 'K" RECEIPT N0. DATE I BY NOW OW _ USE OF BUILDINGS �Y f TRUNK PERMIT NO. NO. DESCRIPTION OF WORK A_ r6EE -- - HOUSE SEWER CONNECTING TO ROAD PERMIT NO. PUBLIC_SEWER @ $ 3.50 STATE ENCROACHMENT HOUSE SEWER CONNECTING TO PERMIT NO. PRIVATE DISPOSAL SYSTEM 1.00 CONNECT AODITIONAI B1 DG.OR INDUSTRIAL _ WORK TO HOUSE SEWER 1.00 WASTE APPROVAL ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM 1.00 I CONNECTION DATA biSCONNECT AND ABANDON SEWER AND/OR DISPOSAL SYSTEM 1.00_ STATION DEPTH SEPTIC TANK,SEEPAGE PIT OR - - --- PITS AND/OR ORAINFiELD 2.00 1 MANHOLE REFERENCE — DESSPOOL—DRYWELL _U_PPFR - LOWER SPECIAL CONDITIONS ONLY 2.00 TYPE OF CONNECTION LENGTH FROM Y, CURB P L M.L.TO P.L. OWNERS PERMIT ; 1 00 AUTHORIZATION i TOTAL FEEIHAVE THIS DATE CONTRACI - NAED CONTRACTOR TO CONNECT THTE ABOVE D SCRIBEDWITH THEI EXISTING APPROVALS INSPECTOR'SSIGNATURE DATE DWELLING TO THE PUBLIC SEWER s SIGNED THIS.---, -DAY OF- -- --------_ 19_..:... NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT._._._,._.._..- BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) ADDRESS .. ----- ----- ----------------- AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[DDRYWELL E] CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER REGULATING PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM _ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT ABANDON HOUSE SEWER _ AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ER OF THE ABOVE DESCRI"D RES,1{d;ENTIAL PROPERTY. BACKFILL SEPTIC TANKS r} �/ f'cq SEEP.PIT(S)o CESSPOOLS ll SIGNATURE f � .` � a' OF PERMITTEE_ sY., i 6A642D 663 12/:12 WORKERS' COMPENSATION DECLARATION I,hereE3v, ,dffirrr tfiat'1 Have a certificate of consent to self 92-0002 DPW s:az y1 4nsure, 9�a certificate of Workers'Compensation Insurance, or CE 808 o u a certif�ie o .y r Sec. 3800, La C. r CE aoa P�olicyl9ompanyr7 u..�, _ , APPLICATION FOR PERMIT L1+ Certified ,:.any is hereby furnished. SEWER - SEWAGE DISPOSAL f ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY department. DateApplica a FOR APPLICANT TO FILL IN CONNECTION DATA CER. IFICA`TE OF EXEMPTIO FROM WORKERS' BUILDING STATION DEPTH COMPENSATION INSURANCE ADDRESS �7G� A3— UPPER (This section need not be completed if the work involved by the LOCALITY MANHOLE REFERENCE LOWER permit is for one hundred dollars ($100)or less.) that in the performance of the work for which this NEAREST TYPE OF CONNECTION LENGTH FROM I certify P CROSS ST. V Y. CURB P.l. M.L.TO P.L. permit is issued, I shall not employ any person in any manner C. so as to become subject to the Workers' Compensation Laws. OWNER CO.IMP.NO. P.JOB NO, B NO MAIL –y ! TRUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS ✓ NOTICE TO APPLICANT: If, after makingthis Certificate Of �.` �� -V —Y;7 e 9/ AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO DATE CITY Yw� TEL.NO J T" 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 f -„� 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 ChapterTSE OF �u 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS J CHARGES ness and Professions Code, and my license is in full force and effect. L CONTRACTOR f CONNECTION CHARGE FEE License Number y LL Lic.Class ESS o 2 �� REIMBURSEMENT FEE C' Contracto �/ a"'+ r� DISTRICT NO. GROUP MAP PROCESSED BY O {a/ ' _Date T CITY �yt TEi.NO `* BK PG C� Z STATE �—{� LIC.❑ �J Y\ Q I am exempt under Sec. of the L.A.Co. LICENSE No. � ��O CLASS . U Plumbing Code and/or Sec, of the NODESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO I + -,ra DATE �•�,-/ VALID ION W IrL B. & P. Code for the following reason PUBLIC SEWER 4_5 0SEPTIC TANK,SEEPAGE PIT OR FINAL PITS ANDJOR DRAINFIELD -- Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG.OR 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 ❑ 1,as owner of the property,or my employees with wages as { e e a e } their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business Permit $ f' i ® 7 (-r and Professions Code). OWNER'S Z 1 ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION I TOTAL FEE L2 E licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE P LIC SEWER. 7. C BCONSTRUCTION LENDING AGENCY ( F i~ I hereby affirm that there is a construction lending agency SIGNED THIS D OF 19_ ► for the performance of the work for which this permit is OWNER OR P P OWNERS AGE issued (Sec. 3097, Civ. C.). ADDRESS— Lender's DDRESS__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 laws regulating Plumbing and Sewers, and hereby authorize representatives of this County to enter upon the above-mettion rty for inspection purposes. Z � Signa ure of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE