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Home My Public Portal About5321-5323 VILLAGE CIRCLE DR_Sewer__ 76A 642D - CE808 - 9/73 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER- SWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING, . ADDRESS A - i LOCALITY NEAREST FOR APPLICANT TO FILL IN GRoss sr. LEGAL DESGRI PTION L07 NO. - OWNER .fit. ' ^ .a MAIL -'TRACT e"`5 -� - ADDRESS NO. OF BLDG5. SIZE OF LOT NOW ON LOT CITY TEL. NO. US€ OF - DISTRICT NO. GROUP MAP PROCESSED BY BUILDING S K P G CONTRACTOR . tY f _ r� i.. Vr)LLI' .L' f�•.. �j s ;,i'�' q �. }, �`: ADDRESS ze ' j" CONNECTION DATA .�` C' r STATION -f +� - DEPTH CITY TEL. NO. if- STATE ' LICMANHOLE REFERENCE .,F�,_� f ,;,;E : v UPPER t - LICENSE NO,.. CLASS ivy, I y . ( /'I— NO. 1 DESCRIP ION OF WOIRK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO CURB P.L. M.L.TO P.L. PUBLIC SEWER 0 $7,00 !t• f ::;�'� P.C.NO. ,J:. SEPTIC TANK,SEEPAGE PIT OR JOB NO. J� PITS AND/OR DRAINFIELD 0 310.00 CO.IMP.NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. PRIVATE DISPOSAL SYSTEM 0 $3.00 CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wA1v1R E411MINT RECORD.INSTR.NO. DATE WORK TO HOUSE SEWER 0 $3.00 S. OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN..CESSPOOL.DRYWELL. 0 $5.00 ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING SEWER OR DISPOSAL SYSTEM _ 0 33.00_ STATE ENCROACHMENTCD MANHGLE $7 00 PERMIT NO. V - -� INDUSTRIAL d Ltd WASTE APPROVAL f!7 OWNERS PERMITE TS CHARGES t)" CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE 3 - -- I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED,,tON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING — -- TO THE PUBLIC S ER. - APPROVALS DATE INSPECTOR'S SIGNATURE SIGN F --T.HIS �,.DAY OF '�' F9 OWNER ..,�,,,� s NEW HOUSE SEWER OWNERS AGENT _ T CONNECT ADDITIONAL ADDRESS ` BUILDING OR WORK — �— •SEPTIC TANK,SEEP,PIT(S). I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -- WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL Cl t HE EBY t9SF7TIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR I.ICEN -D AS R gUIRED BY LOS ANGLES G TY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFC IA OR THAT I AM THE LEGAL O ER F. A�fy. gGFiD TO D45CONNECT PLUG AND — RESIDE I OVE OE i sBEO RE AL PRS ABANDON HOUSE SEWER SIGNATURE ' OF PEQMrTTE BACKFILL SEPTIC TANKS ❑ - *T SEEP.PIT(S) ❑ CESSPOOLS ❑ VALIDATION CK. M.0. CASH WORKERS'COMPENSATION DECLARATION f j I hereby affirm that I have a certificate of consent to self 4 i} insure, or a certificate of Workers'Compensation Insurance, or 76A642D C! certified copy there 3 — C.>, CE 808(REV.B,B,, APPLICATION FOR PERMIT Policy No.8.1`"'� L Company anyy 64�v! '� ts ❑ Cified copy is hereby furnished. SEWER - SEWAGE DISPOSAL `Certified copy is filed with the county ilcl ng in Pe on COUNTY OF LOS ANGELES BUILDING AND SAFETY departnt.��y r. '. p yy` Date '!ApplicantF —�/�= 4^ FOR APPLICANT TO FILL IN CONNECTION DATA CERTIFICATE OF EXEMP ON FROM WORKERS' BUILDING j � N DEPTH ESSr , p COMPENSATION INSURANCE ADDRSTATIO (This section need not be completed if the work involved by the 7 MANHOLE REFERENCE UPPER LOCALITY LOWER permit is for one hundred dollars ($1001 or less.) NEAREST }�s TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST. !J 4 .d w/" Y. CURB P.L M.L.TO P.L. permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws. OWNER f,�f�i�{rG';,�' CO.IMP.NO. JOB(= C�"� f NO.No. O JOB MAIL TRUNK PERMIT NO. ROAD PER MI NO. Date Applicont ADDRESS0 111 AFFIDAVIT WAIVER EASEMENT Y RECORD STR,NO. DATE NOTICE TO APPLICANT: If, after making this Certificate of CITY t TEL.NO. 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 '3 comply with such provisions or this permit shall be deemed revoked. BLACK TRACT STATE ENCROACHMENT f m LICENSED CONTRACTORS DECLARATION No.OF BLDGS PERM!T Aro. SIZE OF LOT NOW ON LOT I hereby affirm that I am licensed under provisions of Chapter USE OF 9 (commencing with Section 7000) of Division 3 of the Busi- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and _, effect. �,, cp CONTRACTOR �,�` :^' L E,F�`• r �q CONNECTION CHARGE FEE License Number �' LiC.CIOSS 4 ADDRESS �� tjfE < REIMBURSEMENT FEE COntracto L-�/77-- Date �E � A� At,) - '�.I DISTRICT NO. GROUP MAP PROCESSED By CITY ! � TEL.NO. 7 BK PG ❑ I am exempt under Sec, of the L.A.Co. LICENSE No. CLASS 1 4{ .1 ,1a NO. DESCRIPTION OF WORK FEE Plumbing Code and/or Sec. of the FINAL 11 -44 HOUSE SEWER CONNECTING TO DATE VALIDATION B. & P. Code for the following reason PUBLIC SEWER — SEPTIC TANK,SEEPAGE PIT OR NAL PITS AND/OR DRAINFIELD FINAL �4Jfe HOUSE SEWER CONNECTING TO BY - .� PRIVATE DISPOSAL SYSTEM Signaturef> "� �� t �� CONNECT ADDITIONAL BLDG.OR OMIER-BUILDItECLARATION WORK TO HOUSE SEWER I hereby affirm that I am exempt from the Contractor's License OVERFLOW TNU.S SEQEPOLGDRyWDRAMANHOLE 'LOW for the following reason (Secton 7031.5, Buisness and Pro- ALTS REPAI R ABANDON HOUSE 'fe SsiOns Code): SEWS P05A1.SYSTEM ❑ I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered for sale (Section 7044, Business and Professions Code). OWNER'S Permit $ LO (� E] I, as owner of the property,am exclusively contracting with AUTHORIZATION TOTAL FE I I t licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RACTOR TO Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 for the performance of the work for which this permit is OWNER OR OWNERS AGENT v, issued (Sec. 3097, Civ. C.). ADDRESS Lender's Name Lender's Address Certify that 1 have read this application and state that the wf above information is correct, I agree to comply with all County ardinances and State laws regulating Plumbing and Sewers, find hereby authorize representatives of this,County to enter Pon the ab ve-mentioned pro eK`'for ins G>I'on purposes. �Si"on jure of Permute Date SEE REVERSE FOR EXPLANATORY LANGUAGE