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Home My Public Portal About5610 WELLAND AVE_Sewer__ z� ?SAS4 76A54 2q tD.G APPLICATION FOR PERMIT - COUNTYZ ELES DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL IJ BUILDING AND SAFETY DIVISION BUILDING � I, ADDRESS .� s,1' - JGNN A. LAASElE, County Eagineer t1 iLLIAM A. JENSEN. Supt of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST r O s.S Ong 1.61 NO, OWNER " J 5 •.fi^' -y C2 MAIL BLOCK Y ADDRESS _ tiff s - --- tan OF SLOGS, 5iL[' O ' T NOW C+'4 LO'- IT fy/.'/ `. �. � .%a:. ., STEL. NO Bli ii_i�IN£+5 DISTRICT Ai O. GROUP MAF PROCESSED BY BK PG' -_ CONTRACTOR.._ r_ ADDR S, CONNECTION DATA . CITY _.. STATION DEPTH "F_L. 14 O. _— - STATE _ UPF`ER R +.aT�Y ATION NO - - C0" N Y MANHOLE REFERENCE RE.NCE z' -LOV3$Y__.- �S. N rFSt'R r't 14id OF WORK FEE 'TYPE OF CQN'NTftTION LENGTH FROM .:. ti V sc St YEP'CONNECT';NG TO —- - --_.. _�__� -- Y ;'C:i}RB P.L. F.4.L.TO P.L. PUBL C'SEWERS.Op F G NO. i PITS AND OR DRAIN LD c $'I()-OO C3.IMP.NO JOB NO.—_„„ HnUS_ ER NE(. Nfi n _-I PR LATE DISPOSAL. DI P-a AtSAL.5—STEM $S.,CO � D30:dK PETI M:T NO. ROAD PERMIT NO,'- AFF;1AV_!_Ti W'AiviR EASEMENT NO. "�. DATE WRK TO HOUSE SEW}R33.00 ' --_ -. - __ H LCJWE'E' _PAG—E PIT DR-AIN FIEELD _L_—___ EX7N CE SPVOL,DRYWE __,M NHOLE CL $5.00 HWY.OR ST WIDENING AL EWER OR R DISDISPOSSCABANDON AL SYSTEM ENCROACHMENT ATE 'fPERMIT NO. INDUSTRIAL 1 WASTE APPROVAL_ CHARGES OWNER'S PERMIT -, -' - �� _2+oo - - --- - -- - -- AUTHORIZATION TOTAL FEE - - CONNECTION CHARGE FEE I HAVE AT THIS DATE A CONT'RA:' W;TH THE HEREIN NAMED CON- REIMBURSEMENT PEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- �q�g--- ---- --T---------- - -- - ------ TOTHEF�UBLJC W.E;R. APPROVALS DATE ItNSPFCTORS i 'NATURE SIGNED THIS—,:r_DAY OF - ----- OWNFR OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADD;TIONA.L BUILDING OR WORK SEPTIC TANK SEEP PI TlS; -- I HEREBY ACKNOWLEDGE THAT I HAVE READv THIS APPLICATION AND STATE THAT THE ABOVE tS CORRECT AND AGREE TO COMPLY AND/OR DRAt N,:I:Ec.D WITH ALL.. COUNTY ORDINANCE AN'D STATE LAWS REGULATING ❑ PL JM'3IiNG AND SEWFRS. CESSPOOL {__F DRYWELL I HEREBY CERTIFY ?HAY AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR --j- _�---------_`�-�-- LICENS_D AS REQUIRED BY ILOS ANGLES COUNTY AND SPATE, OF SEWAGE DISPOSAL SYSTEM 4ER OF, AND INTEND TO '_._ :_._._ ___.____�� ____a__ __�__ ___—.._.. CALIFORNIA H THAT I AM 7HE LEGAL OW'n DISCONNECT PLUG AND I RE^sipE. IN, THE ABUYE- D'E'S C.RIBFD FTESIDEN7t(aj„ PROPERTY. ABANDON HOUSE SEWER SIGNATUREOF PERMITT'EI:_ _�— ,�±��,�— B.4CKF'ILL SEPTICYA°Y KS SEEP,ILL(SS) ❑ Cc.SSP'OOS,S ❑i _�__.—__—.� _--'VALIDATION ROBERT A. WOOD SUPERVISING MECHANICAL ENGINEER WORKERS'COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self 92-0002 DPW 3/87 insure, or a cf.*ificate of Workers'Compensation Insurance, or 76A642D a certified copy thereof(Sec. 3800, Lab C.) CE 808 APPLICATION FOR PERMIT Policy No. Company ®s ❑ 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' BUILDING t STATION DEPTH COMPENSATION INSURANCE ADDRESS ( f.. I.ti �L,Q,A,'C, -Z"� 7 (This section need not be completed if the work involved by the UPPER �(}r , permit is for one hundred dollars ($100)or less.) LOCALITY MANHOLE REFERENCE I certify that in the performance of the work for which this NEAREST 4`^! PC..}, TVPEOFco �rloN P.L. M,I,TO P.L. CROSS ST. f L` LENGTH FROM . C permit is issued, I shall not employ any person in any manner F' so as to become subject to the Workers'Compensation Laws. OWNER 0 4't1/, p / • P.C.No. t�tL,��.�-(s�IVC:C,.IMP.NO. �� J08 NOMAIL . RUNK PERMIT NO. ROAD PERMIT NO. Date Applicant ADDRESS 14-01; this Certificate of d�t ``4�-Wt? t 2L ( `! AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE NOTICE TO APPLICANT: If, after making CITY �R ) �•. 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 ChapterUSE OF 9 (commencing with Section 7000) of Division 3 of the BUST- BUILDINGS CHARGES ness and Professions Code, and my license is in full force and effect. CONTRACTOR CONNECTION CHARGE FEE License Number Lic.Class ADDRESS REIMBURSEMENT FEE d DISTRICT NO. GROUP MAP PROCESSED BY Contractor Date V CITY TEL.NO. BK El am exempt under Sec. of the L.A.Co. STATE LIC. fj µ OPG yd'. O LICENSE NO. CLASS ,Ir" /' f �Y' Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE FINAL HOUSE SEWER CONNECTING TO DATE. VALIDATIONW B. 8 P. Code for the following reason PUBLIC SEWER r CL SEPTIC TANK,SEEPAGE PIT OR FINAL Z PITS AND/OR DRAINFIELD Date HOUSE SEWER CONNECTING TO BY PRIVATE DISPOSAL SYSTEM Signature CONNECT ADDITIONAL BLDG-OR OWNER-BUILDER DECLARATION WORK TO HOUSE SEWER , I hereby affirm that I am exempt from the Contractor's license OVERFLOW SEEPAGE PIT,DRAINFIELDExTN.,CESSPOOL,DRYWELL,MANHOLE Law for the following reason (Secton 7031.5, Buisness and Pro- ALTER,REPAIR OR ABANDON HOUSE 777111 fessions Code): SEWER OR DISPOSAL SYSTEM d I,as owner of the property,or my employees with wages as h -fid- &t 1 L 6t-4V c'AT 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 g p'/7l 7-1- ❑ I,as owner of the property, am exclusively contracting with AUTHORIZATION TOTAL FEE licensed contractors to construct the project (Section 7044, 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CONTRACTOR TO Business and PfOfe55iOr1S Code). CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER. •- CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency SIGNED THIS DAY OF 19 o _ for the performance of the work for which this permit is OWNER OR OWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS ,I Lender's Name Lender's Address I certify that I have read this application and state that the above inforrnotion 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 r�fC�"T, E`t"jlffiIV4 C ii