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Home My Public Portal About6411 TEMPLE CITY BLVD_Sewer__ Tan eAxD—ceaoE—ID-TI I-on p6,F Ow APPLICATION FOR PERMIT �J COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION bull" E77 ^ ADDRcae L. Y MAIL LOCALITY N[AR[ST FOR APPLICANT TO FILL IN =Roan BT COAL Dt Ftl PrION LOT No OWNER !LOCK TRACT b ADDRESS a67 X/ NO OF ELD00 — BII[ OF LOT ryOW ON LOT CITY 'TEL NO uae OF aUILDINO6 LL DISTRICT NO GROUP MAP ROCESSCD aY T BK POS/ CONTRACTOfl j,O$ Oji � — � J ADDRESS CONNECTION DATA CITY TEL NO STATION DEPTH Start IT [J SSP R STATE Q NO LIC MANHOLE REFERENCE REO y 0 J,. J/X O NO DESCRIPTION OF WORK FEE TYPE OFC ION I a LENGTH FROM / HOUBE SEWER CONNL=TIXO TO Y CUR P L Y L TOIL PUBLIC SEWER 0 .�] 00 13,77 PC NO SEPTIC TANK SEEPAGE PIT Ofl PITS NO/OR DRAINFIELD CI000 CO IMP NO JOS HO HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O PRIVATE DISPOSAL SYSTEM ES 00 CONNECT ADDITI ORAL BLDG OR AFFIDAVIT R.IYEF T..FRFNT RECORD INSTR NO DAT[ V WORK TO HOUSE SEWER 0 ES OO OVERFLOW SEEPAGE PIT DRAINFIELO O IKTN C[SEPIOL DRYWELL Y SSW HWY OR ST WIDENING ALTER REPAIR OR ABANDON HOUSE !EWER OR DISPOSAL SYSTEM C [i 00 STAT[ENCROACHMENT MANHOLE 0 fT 00 PERMIT NO d INDUSTRIAL }��p WASTE APPROVAL CHARD" PERMT f 0 OO AUMOFMTION TOTAL PEE CONNECTION CHARGE F[! 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED E%1ST NG OWELLINO AOVA� TO THE PUBLIC SEW[ DATE INSPECTOR S SIGNATURE SIGNED THIS DAY OP IR_ OWNER OR NEW HOUSE SEWER OWN ERSAOCNT CONNECT ADDITIONAL AGGRESS BUILDING OR WORK SEPTIC TANK SEEP PIT(B) 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD AND STATE THAT THE ABOVE Ia CORRECT AND AOREC TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING FLU Ma ING AND SEWERS CESSPOOL ❑ DRYW[LL El 1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR S[WKR OR LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER SIGNATURE OF P[RMTTTEQ BACKFILL SEPTIC A S ��Ep�TaT[EP PIT mi • POOLS V7TION cK M 0 CASH L/�/]yv� 524�-'APR 41u U 10.00 'am WORKERS COMPENSATION DECLARATION s� I hereby affirm shot I have a ceHihcate of consent to self ZD OOBI DPW ISTM u mswe or a certificate of Workers Compensation Insurance or 7BA0420 o copy thereof (Sec Lab n APPLICATION FOR PERMIT Pollicyacy No No Companyny - SEWER - SEWAGE DISPOSAL ❑ Certified copy is hereby furnished ❑ Certified copy is filed with the county building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY deportment 67 14-11 Dote Applicant FOR AflIPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMPTION FROM WORKERS BUILpNG COMPENSATION INSURANCE ADDRESS O le B 11 -r.4 STATION DEPTH (This section need not be completed If the work Involved b the UPPER PER P by LOCALITY MANHOLE PEFERENCE` T 4 permit Is for one hundred dollars ($ or less ) L LENGTH FROM I certify that in the performance off the the work for which the NEAREST TVR OF CONNECT(ION , CROS.ST Y CURBi PL ML TOPL permit is issued I shall not em an rson m any anner LEGAL PC FRO so as to become subject tot orkers emabo Laws GEBCWPTION LOT NO CO IMP NO Roe NO FLOCK TRACT TPUNK PERMIT NO GOAD PERMIT NO Date I �' Apphcont NOTICE TO APPLICANT If oft ma4in this Cerbhcote o1 ASSESSOR AFFIDAVIT WAIVER EASfM1ENT RECORD INSTR NO DATE 9 MAP BOON PAGE PARCEL Exemption you should beco a subject to the Workers No OF BLDGS Compensation provisions of the Labor code you must forthwith SIZE OF LOT NOW ON LOT HWY OR Sr WIDENING comply with such provisions or this permit shall be deemed USE OF revoked WILDiN STATE ENCROACHMENT PERMIT NO LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter OWNER 9 (commencing with Section 7000) of Division 3 of the Bust MAIL s H , fL _� CHARGES ness and Professions Code and my license is in full force and effect CIDO TY TEL N p CONNECTION CHARGE FEE License Numbe. Lic Class CONTRACTOR RTiMeuRSEMFNT FEE Contractor Dote DISTPICT NO C4CUP MAP ESSFD By ADDRESS /per L Bx PG ' ❑ I am exempt under Sec of the L A Co Gln, TEL NO Plu mbi ng Code and for Sec ofthe STATE UC FINAL U IJCENSE NO CLASS DATE O e V LID TION 2 B 8 P Code for the following reason NO DESCRIPTION OF WORK FEE '/L'/ 0 Dale PU&SC SMWER EWER CONNECTING TO BNAt SEPTIC TANK SEEPAGE PIT OR a Signature PITS AND OR DRAINFIELD y OWNER BUILDER DECLARATION HOUSE SEWER CONNECTING TO , I v} 2 I hereby affirm that I am exempt from the Contractor s License I IrIONAT&oG ./4Av L L'd//A1-W Low for the following reason (Secton 7031 5 Buisness and Pro 1� 10 lessons Code) WEPFLOW SEEPAGE FIT GRAINFIELD I CESSPOOT ORYWELL MANH«E ACCT.` ❑ I as owner of the property or my employees with wages as ALTER REPAIR oR ATANDON HOLM • -" / t thou sole compensation will do the work and the structure SEWER Ott DISrbSAL SYSTEM is not Intended or offered for sola (Section 7044 Business 3303 43.40 and Professions Code) 1 ITEILS ❑ 1 as owner of the property am exclusively contracting with PBfTIi S TOTAL 43 4Q licensed contractors to construct the project ISection 7044 OWNER'S Business and Professions Code) AUTHORIZATION I TOTAL FEE MILK 43.40 CONSTRUCTION LENDING AGENCY HAVE AT THIS DATE A ewTPACt WITH THE HEREIN NAMED"IRACIOR ► LE�K��TF�f�LI hereby affirm that there is a construction lending agency CONWT THF ABOVE DESCRt&D E+6tiNG DAKELLING TO THE% CI"@91P�r .00 for the performance of the work for which this permit is issued (SBC 3097 Civ C I SIGNED THIS DAV Of I9_ op Lender s Name OWNEa OWNF PS AGENT 0000-0001 1/29/96 A Lender s Address ADDRESS 4510 1 AN 10:17 1 certify that I have read this application and state that the above In abort n correct I agree to comply with all County nces o d State laws regulating Plumbing and Sewers nil hereby uthonxe re rasentabves of ihrs County to enter upbn thea non d properly for Inspection pwpases nature of Permittee Dole SEE REVERSE FOR EXPLANATORY LANGUAGE