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Home My Public Portal About9623 VAL ST_Sewer__ f400 INSEM OR 00 a ao COUNTY OF LOS ANGELES ATI ON FO EW RASE AGE DISPOSAL 1 Tue+ao DEPARTMENT OF COUNTY ENGINEER BMLDMG AND SAFETY DIVISION BUILDING 1_ ADDRESS ViQSlAN A. ]P178H1 Bop? 0!D ad.9 LOCALITY �7 , RAREST L /J� FOR APPLICANT O FILL IN CROss Sr /C L LEGAL DESCRIPTION LOT NO OWNER BLOCK TRACT ` ` PAIL ADDRESS za� IF NO OF BLDGS SIZE OF LOT NOW ON LOT CITY EL NO USE OF BUILDINGS . DISTRICT NO GRO BL LSSLD MAP PROCBY � PG CONTRACTOR,,"f_.,/ /, S r d ADDRESS CLQ � J CONNECTION DATA CITT / TEL NO -�. STATION DEPTH REGISTRATION NO ! �Z 7 ! CYT COUNTY TXTE �MMOLL REFERHNCH O J PPER wo DESCRIPTION F WORK FEE J HOUSE SEWER CONNECTING TO PUBLIC$EWER4p 33 00 7 TYPE OF CONNECTI LENGTH FROM/ SEPTIC TANK SEEPAGE PIT OR T CURB F L Y L TO P L PITS AND ON DRAINFIELD OVERFLOW SEEPAGE PIT DRAINFIELD M CE POOL D TW 00 HOUSE SEWER CONNECTING TO ,�D JOB RO PRIM D�LIS LSLLST 100 co IMF NO NORK C XOUSEI9EMEBLDG OR0 21.00 TRUNK PERMIT NO ROAD PERMIT NO V gg% EPA R OR ABAND N ROUSE I OO STATE ENCROACHMENT MI PERMIT NO INDUSTRIAL WASTE APPROVAL CHARGES OWNER'S FERNIIT 2 00 CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE REIMBURSEMENT ME6 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAM SD CON' TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING WELLING APPROVALS DTH INSPECTOR 48IGNATURE T I THE PUBLIC SEW g� SIGNED THIS— AY OF 9_ NEW HOUSE SEWER I'1 B OWNERSDACONNECT ADDITIONAL ^"� BUILDING OR WORK ADDREB ANO/ORTPIT(S) DRAIMFIE I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COYPU CESSPOOL 11 DRYWELL 11 WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR _ PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I A■ PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSES AND CALIFORNIA OR THAT I AY LEG NLR OF THE ABOVE WER DESCRIBED RESIDENTIAL ERTY BACKFILL SE C TANKS SIGNATURE A BEEP PIT S CESSPOOL! OF PERRI mTATION ROBERT A WOOD CL ■ o WR SUPKRYISING MECHANICALMECK^NICAL HPIOINBHN �D6030;9 OEC 12 1 0 p 5.00 WORKE&S COMPENSATION DECLARATION f herebytoffum that I have a certificate of consent to self insure, or a certificate of Workers'Compensohon Insurance, or rawsO a certifiedj�P�t�h�e�reof(Sea 3800• Lp�C , CEMWV APPLICATION FOR PERMIT Policy No 112 Company_ r:xl irnlm1 �Certified copy is her join h SEWER - SEWAGE DISPOSAL Cemfiad copy a ftled with th my m ion COUNTY OF LOS ANGELES BUILDING AND SAFETY department Date n:ay—tr Applicant FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE PENSATIONEXEMPTION INSURANCE mceRs ApoRm 96 3 V STATION aVTH al Street (This section need not be completed if the work Involved by theLouLiry MANOIE sFSETETa� UPPER x permit is for one hundred dollars($100)or less ) TYPE OF CONNECTION ILNOIIi FROM I certify That m the performance of the work for which ilia rn�sT w.P/L/i�l v Curtis Pt ML TOP L permit is Issued I shall not employ any person in any manner PC No so as to become subject to the Workers Compensation Laws OWNER John Steenhinird Co IAw NO NOB NO JWMLROAD PERMIT NEO Dote Applicant ADDRESS 9623 Val S TRONK PFRAYi"° NOTICE TO APPLICANT If, after making this Certificate of ciE T C• TEL NO AFFIDAVITwANER EASEMENTRECORD ItvsTR NO DAN Exemption you should become subject to the Worker Compensation provisions of the Labor code You must forthwith DESCRIPTION LOT NO HIWY OR ST WIDENING comply with such provisions or this permit shall be deemed revoked BLOCK TRACT STATE ENCROAOIMEM LICENSED CONTRACTORS DECLARATION um SIZE OLOT NOW ON LOT NO a BLDGs 21PE°'wr PE) F I hereby off that I am licensed provisions uncle;prov ons of Chapter � 9 (commencingeEa with Section 70DO) of Division 3 o! the Bust sullos s CHARGES ness and Professions Code and my license is in full force and effect CONTRACTOR T. A Russell Construction Co CONNECTION CHARGE FEE LlcensaAWgib r i lass ADDRESS REIMBURBFA1ENr y Connoct —oI�-1 tDJ GROUP Aso BY Oct uTv Ta NOPQ v ❑ I am exempt Sec of the L A Co LII�nE NO 353614 ASS 114 °L Plumbing Code and/or Sec of the NO DESCRIPTION OF WORK PEP O -HOUSEPUBISE SELLER CONNEaING TO VALIDA NB 6 P Code for the following reason NK AGE PIT OR Date NTS AND/OR DRAINFIELD HOUSE SEWER CONNECTING TOPR ASignature ( CONNECT ADDITONAL SLOG OR��OWNER-BUILDER DECLARATION WORK TO HIOUSE SMIER -I ERPL SEEPAGEPa NPR 82761 A I hereby offirm that 1 om exempt from the Contractor s License CCSSPOOL DRYWTu MANHOLELaw for the following reason (Secton 7031 5, Buisness and Pro $ eeeel0 fesstons Code)❑ 1 as owner of the property or my employees with wages ors e e21,50 their sole compensation, will do the work and the structure is riot intended or offered for Sale (Section 70", Business • e R 21.5 0 6and Professions Code) OWNER'S Permit s0.1 ❑ I as owner of the property am exclusively contracting with AUTHORIZATION TOTAL FEE 11a21 "8.5licensed canha[ton to Conahuct the protect (Section 7046 i HUVE AT IVIS DATE A CONTRACT WIIN THE HERRN NAAIFDBusiness and Profession]Code) CONNECT THE ABOVEDESC f NO DWEL TO THE PUCONSTRUCTION LENDING AGENCYI hereby affirm that there Is o construction lending agency SIGNED THIS D for the performance of the work for which this permit is SPE°O°issued (Sec 3097, Civ COWNERSADEM Lendar s Name Lender s Address I card th vis read this application and state that the ' above f mutton cortect 1 oprae to comply with ail County ordlna and S e laws regulohng Plumbing and Sewers N—SIg and ou iza asentahvM o! this County to entm t i n property fa Inapryec^iion purposes W n Lure of Permittee Dole M 2111VIM FOR WLANATORY LAIgUAOE