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Home My Public Portal About9206 WEDGEWOOD ST_Sewer__ BA6 2D APPLICATION FOR PEOMIT COUNTY OF LOS ANGELES SEWER--SEWAGE DiSPOSAt„ DEPARTMENT OF COUNTY ENGINEER - BUILDING AND SAFETY DIVISION ButLDtN ,►r JOHN A, LIiMBIE, County Engineer ADDRESS WILLIAM A. JENSEN, Sup't of Building LOCALITY ,. NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL DESCRIPTION LOT NO. z OWNER " BLOCK TRACT '�l MAILADDRESS 3i O.OF BLDGS. wg I SIZE OF LOT a NOW ON LOT CITY TEL. N0...; USE DI DISTRICT NO., GROUP MAP PROCESSEC$Y BUILDINGS fi' BIS PG CONTRACT x t ADDRESS CONNECTION DATA CITj f°TEL.NO. r ,�✓. - STATION ��+� _4/ -* _ � DEPTH " STATE .MANHOLE REFERENCEUPPER REGISTRATION NO J COUNTY " NO. 1 DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO PUBLIC SEWER @ S3.004T TYPE OF-CONNECTION LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR Y. CURB- P.L. M.L.TO P.L. PITS AND/OR DRANFIELD @ $3.00 OVERFLOW SEEPAGE PIT,DRAXNFIELD EXTN.,CESSPOOL,DRYWELL @ $2.00 HOUSE SEWER CONNECTING TO P.C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO_ U CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE SEWER $1.00 TRUNK PERMIT N0. ROAD PERMIT NO @ ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT SEWER OR DISPOSAL SYSTEM@ $1.00 PERMIT NO. U LU INDUSTRIAL WASTE APPROVAL t/} CHARGES Z OW,R'S PERMrr 5 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE `Q "' REIMBURSEMENT FEE I HAVE AT DATE A CONTRACT WITH THE HEEIN NAMED CON- TRACTOR TO CiONNECT THE ABOVE DESCRIBED EXIST NG DWELLING APPROVALS DATE. INSPECTORS SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS,DAY OF 19— NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL - BUILDING OR WORK AIIDREBS SEPTIC TANK,SEEP.PIT(S) AND/ORDRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL II DRYWELL El WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALYER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA 6R THAT [ AM THE LEGAL OWNER 0 ABOVE BACKFILL SEPTIC TANKS r DESCRIBED RESIDE TYAL PROP SIGNATURE r ?i_ SEEP.P[T(S) C] CESSPOOLS OF PERMITTE s . VALIDATION` R0515RT A. WOOD Cit. M.0. / CASH SUPERVISING MECHANICAL ENGINEER f. fa 7 . '7.� . _ F C', r �l '.. .t l 4 A WORKERS'COMPENSATION DECLARATION I :hereby offirm that I have a certificate of r„onseYtt'to self' insure, or o certificate of Workers'Compensation Insurance, or 76A642D "a cert fled copy thePeof(Sec."3800, Lab C.) 92-0002 DPW 6,98 APPLICATION FOR PERMIT Policy No. Company ❑ 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' eu1LDING yy COMPENSATION INSURANCE ADDRESS �� : STATION 1 DEPTH (This section need not be completed if the work involved by the MANHOLE REFERENCE, permit is for one hundred dollars ($100)or less.) LOCALITY 04 a; y NEAREST - - TYPE OF CONNECTION LENGTH certify that in the performance of the work for which this CROSS sT. Y. CURB _P I M1 TO P.L. permit is issued, 1 shall not employ any person in any manner RC.NO. so as to become subject to the Workers`Compensation Laws. OWNER ` _ t:, N; 'j � co.IMP.No. °' � roe No. MAIL TRUNK PERMIT NO. ROAD PERMIT NO. Dote Applicant ADDPE S - --- _..�_ _ NOTICE TO APPLICANT: If, after makingthis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD.IN STR-NO. CITY _ 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 comply with such provisions or this permit shall be deemed -' revoked. BLOCK TRACT 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 Chapteru5E 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. CONTRACTOR CONNECTION CHARGE FEE CL^ License Number Lic.Class ADDRESS REIMBURSEMENT FEE 8 DISTRICT N6.T G UP MAP � P SSED BY Z Contractor_ Date CITY TEL.NO. BK PGO ❑ t under Sec. of the L.A.Ca. STATE LIC,am exempt P LICENSE NO. CLASS Plumbing Cade and/or Sec. o#rhe 4.i ,✓/,; NO. DESCRIPTION OF WORK FEE `��3 ,�-• FINAL ' VAcLIDATION CL HOUSE SEWER CONNECTING TO DATE ,�"•,,,. Y B. &P. Code for the following reason PUBLIC SEWER, SEPTIC TANK,SEEPAGE PIT OR `, ` PITS AND/OR DRAINFIELD FINAL Dote HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEMI / - 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 fesslons Code): SEWER OR DISPOSAL SYSTEM - ❑ 1,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 I Permit s IJ IOU ❑ 1, as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE rr-s 5CJ licensed contractors to construct the project (Section 7044, I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME ONTRACTOR TO 1 c Business and Professions Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. "t."Up0 CONSTRUCTION LENDING AGENCY al„ I 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 issued (Sec. 3097, Civ. C.). OWNERS AGENT J 'i ADDRESS Lender's Name - (d T�t:;,.z , ,. Lender's Address _ _3 .,n � _ 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-mentioned property for inspection purposes. Signature of Permitteer Dote SEE REVERSE FOR EXPLANATORY LANGUAGE