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Home My Public Portal About9207 WEDGEWOOD ST_Sewer__ 76 04A 4"` APPLICATION FOR PERMIT ,:c,saz�r u COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION FNE DING RESS ALITY FOR APPLICANT TO FILL IN 55ST OESCRGF'TION LOT NO P OWNER. ',� z3.✓' � MA9L. BLOCK TRAT ``7 C•JY -t �J ADDRESS C �,/ ,p NO. OF BL G5. - SIZE OF LOTy�'j".6_Y,jkpl Y� NOW ON LOTCITY ' --- TEL. NO, USE OF BUILDINGS. . ``'J DISTRICT NO. GROUP I BK 'AAP P PR C£5 SCD B'Y G_ONTR.ACTOR, /_�,% ds� i�'7 GL k•1 _"..Y :�-rL. Y V �r� ✓ fey {) CONNECTION)DATA ADORES ._y.. .9 J'J""7 '� l•' e.. `` y DEPTHSTATION >yCITTEL NO. - Y3 .5LIC . —s�J UPPER 2- G-SiATE SE O. MANHOLE REFERENCE L ECl � _ A{y`LYY�R NO. ..DESCRIPTION O WORK FEE TYPE OF CONNECTION,��h LENGTH FROM HOU-5F SEWER CONNECTING TO ---"- ----- -- ';J Y. -`CURB Ire M.L.TO P.L. _ ! �a'� L1. SEPTIC IANK SEEPAGE PIT OR P.C.NO. --�- PIT5'AND OR DRAINFIELD C'•i CO.'IMP.NO. JOB NO. HOUSE SEWER.CONNECTING TO TRUNK PERMIT NO- ROAD PERMIT NO, PR?VATE DISPOSAL SYSTEM @ _ LIC C ONNE^.T ADpiTIONAI BLDG.OR AFFIDAVIT i wAf VER EASEMERi RECORp.INSTR.NO:. I DATE O - WORK TO HOUSE SEWER @ OVERFLOW SEEPAGE PIT.DRAIN.FIELD i E EXT N..CE$SPOOL.DRY WELL.MAOLt:@ L� ALTER.REPAIR OR ABANDON JHOUSE HWY. OR ST.WIDENING �yy SEWER OR DISPOSAL SYSTEM @STATE ENCROACHMENT PERMIT NO. INDUSTRIAL -- ---- -TA—�-- ��y� `� '. WASTE APPROVAL O 1I1I 1`I.L+R,S PERMIT 75 „a G'4 L'7 — ------- CONNECTION -_.�CHARGES AUTHORIZATION TOTAL FEE ' GJ CONNF_CTION CHARGE FEE `--�- I HAVE AT 'THI$ DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -- - - ---- TO THE PUBL.I i, SEWER. APPROVALS DATE I INSPECTORS SIGNATURE SIGNED THIS---DAY CF�__ T9_ `-- -- ------444------ -- ---._. OWNER OR NEW HOUSE SEWER OWNERS 4.aENT -- CONNECT ADDITIONAL BUILDING OR WORK --' SEPTIC TANK.SEEP PIT(S) I HEREGV ACKNOWLEDGE THAT!HAVE READ THIS APPLICATION AND/OR DP.A.INFIE.LD AND TATO THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY __._--__-__.___.._---..--_- WtTF- AL COUNTY ORDINANCES AND STATE LAWS. REGULATING T —� MBING AND SEWERS. CESSPOOL ❑ DRYWELL I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND!OR ALTER REPAIR.SEWER OR 1 LIc.EN SEO AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM 1 CALIFORNIA OR THAT I AM THE L GAL OWNER OF AND JNTEND TO "-- -- — '—'-- /' DISCONNECT PLUG AND RESIDE 'N. THE ABOVE DESCRIBED RE$IDEN)IAP RO P TY. EftM?TTEE ABANDON HOUSE SEWER I `_ SIGNATURE •r 'Y..,.�- _��y .-t— _- -.__— .� / f l - BACKFILL SEPTI._TANKS ❑ OF (' dR' / icL:: ° SEEP.PIT(S) ❑ CESSPOOLS VALIDATION CK. h9.0. CASH f 1 'A�1 r F. .i...� 0 1 0.0 0 A ii WORKERS' COMPENSATION DECLARATION I i hereby affirm `ihat I have a certificate of consent to self �I insure, or a certificate of Workers' Compensation Insurance, or 76A642D ,a certified copy thereof (Sec. 3800, Lab C.) CE808(REV.8,81 APPLICATION FOR PERMIT Poi7cy"No, _ Company ®s ❑ Certifik*d 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' i DEPTH COMPENSATION INSURANCE ADDRESS 2-1) 3 C�—L2--yx f STATION f�" l si (This section need not be completed if the work involved by the LOCALITYFi "r Lo. 6 MANHOLE REFERENCE j �S r UPPER permit is for one hundred dollars ($100)or less.) f a I certifythat in the NEAREST x! TYPE OF CONNECTION 1" LENGTH FROM performance of the work for which this CROSS ST. G C,A> a�/� Y CURB P.L,, M.L.TO P.L. I is issued, I shall not employ any person in any manner �� // /�� P.C.NO. 50 ILS 10 become subject to the Worker�Cmpensation' LAWS. OWNER �P'r'6.,..- �/lr-zvx- CO.IMP.NO. JOB NO. MAILTRUNK PERMIT NO. ROAD PERMIT NO. Date ' Applicant 6 AflOREss .�z�` NOTICE TO APPLICANT: If, after makingis Certificate of AFFIDAVIT WAIVER EASEMENT RECORD,INSTR NO. DATE CITY TEL NO. Exemption, you should become subject to the Workers' LEGAL Compensation provisions of the Lobar 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 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. CONTRACTOR - CONNECTION CHARGE FEE License Number Lic.Class_ €T ADDRESS REIMBURSEMENT FEE Contractor Date D'STRICT NO. GROUP MAP PROCESSED BY CITY TEL.NO. STATE LIC. ELK PG El am exempt under Sec. of the L.A.Co. LICENSE NO. CLASS ?A(1 6{(�. !1 Plumbing Code and/ NO DESCRIPTION OF WORK FEE or Sec. of the FINAL � � VALIDATION H HOUSE SEWER CONNECTING 70 DATE PUBLIC SEWER t!y B. & P. Code for the following reason SEPTIC TANK.SEEPAGE PIT OR Z PITS AND,,OR DRAINFIELD FINAL Date HOUSE SEWER CONNECTING TO BY DISPOSALPRIVATE Signature CONNECT ADD I ZONAL BLDG OR k �1 r OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER OVERFLOW SEEPAGE PIT, I hereby affirm that I am exempt from the Contractor's License EXTN.,CESSPOOL,DRVWELL,fII,MANHOLE Law for the following reason (Secton 7031,5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE. fessions Cade): SEWER OR DISPOSAL SYSTEM �f ❑SNI, 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 $ ❑ 1,ILS owner of the property, am exclusively contracting with AUTHORIZATlOF41 TOTAL FEE I zz) 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 PUBLIC SEWER, CONSTRUCTION LENDING AGENCY Pilo 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 ADDRESS 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-mentioned property for inspection purposes. Signature of Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE a