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Home My Public Portal About9157 WOOLLEY ST_Sewer__ . 76AG420 - �pPLI C.ATI®I®I FOR PERMIT � .._..,. _.. 1 8 A E-003 12.54 DIVISION OF BUILDING AND SAFETY SEWER--S EWAG t•fir D 1�t- SMSA 1. Deparbuent of County Engineer County of Los Angeles BUILDING WM.J. FCX, COUNTY ENGINER ADDRESS CA5SATT D. GRIFFIN,SUA'Y OF 6U111DING ' LOCALITY FOR APPLICANT TO FILL IN NEAREST ��.�fi=r��`i • ,Y CROSS ST. _O-W LEGAL DESCRIPTION LOT NO. +mss OWNER ,a,�., BLOCK TRACT ' 43 y ,,. MAIL _ ---- ADDRESS gas ` L '' '•+-^` NO. OF BLDGS. 512E OF LOT NOW ON LOT' CIT v 1, ca x"_ 9 .TEL. NO If ,semp�T = USE OF BUILDINGS .—_ DISTRICT NO. GROUP i MAP BK FG CONTRACTOR � _ - ADDRESS r ,� CONNECTION DATA CITY " TEL NO./-- f r-' STATION DEPTH - ..,„._ - ❑ STATE - MANHOLE REFERENCE _ G frt / CI REGISTRATION NO. COUNTY Upip R LOWER _ _ _.._.. _ _..G.� _ TYPE CF CONNECTION LENGTH FROM r - 'f;- CGn,�- P. TO P.L. ht.L. NO. { DESCRIPTION OF WORK FEE _ ----._....-__...__ ... �. �iHOUSESEV ER CONNECTING TO PUBLIC_SEWER _ _ 0q $ 3_O--I,��, T� HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 ------ CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. � - JOB. NO. WORK TO HOUSE SEWER _ 1,00 I I` ALTER OR REPAIR EXISTING SEWER OR DISPOSAL SYSTEM_ 1.00 �. TRUNK PERMIT NO, ROAD PERMIT NO, DISCONNECT AND AE NDON SEWER 1.00 STATE ENCROACHMENT i _ F ND OR DL S ISPOSAYST_E,M 1,6;1_1 FERM.IT NO. SEPTIC TAY ,SEMI A+ PIT OR PICS AND/OR DRAINFIELD 2 00 ! j INDUSTRIAL ^'ICESSPOOL DRYWELL WASTE APPROVAL Sj>CIAL CONDITIONS ONLY 2 00 I CHARGES CONNECTION CHARGE FEE OWNER'SPERMIT 9 08 --- - --- AUTHORIZATION 'TOTAL FEE ---{ REIMBURSEMENT FEE i I HAVE THIS DATE CONTRACTED WITH THE. HEREIN NAMED CON- er �n TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE ^� TO THE PUBLIC SEWER .'... NEW HOUSE SEWER SIGNED THIS -DAY OF a°� �� 7�3.�.� __� OWNER ORN �� CONNECT ADDi710NAL OWNERS AGENT .'V:. _BUILDING OR WORK_, SEPTIC TANK SEEP, FIT(5) AND/OR OR DRAINr'IELa I HEREBY ACKNOWLEDGE THAT I HAVE RtAD.THIS APPLICATION � CESSPOOL E3 DRYWELL0 AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY, WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, 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 OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE D,SCR14E-D RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ SEEP.PIT(S) ❑ CESSPOOLS Q SIGNATURE' - _ ._... OF PERMITTEE' WILLIAM J. F ,COUNTY ENGINEER VALIDATION By DEPUTY DEPUTY BY BY '`i DEPUTY - DEPUTY WORKERS'COMPENSATION DECLARATION " •` affirm that I have a certificate of consent to self insure- or a certificate of Workers'Compensation Insurance, or 9A5a2D a certified copy thereof (Sec. 3800, Lab C.) CE 908(REV.1/83) APPLICATION FOR PERMIT Policy No._. —Company! El 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 / Cl�<' (This section need not be completed if the work involved by the LOCALIoJ. , MANHOLE REFERENCE OWER NEAREST permit is for one hundred dollars ($100)or less.) Tv NEAREST TYPE OF CONNECTION LENGTH FROM I certify that in the performance of the work for which this CROSS ST, Y. CURB P L M.L.TO P.L. permit is issued, I shall not employ any person in any manner P.C,No, so as to become subject to kers'C pensatioon_Laws. OWNER j � rGrCf/�L-��'�'�L[��_ CO IMP NO, JOB NO, MAILDate C�� %Applicant ADDRESS TRUNK PERMIT NO ROAD PERMIT NO. AFFIDAVIT WAIVER EASEMENT RECORD,INSTR.NO. DATE NOTICE TO APPLICANT: If, after mokin t is Certificate of CIT;iv- t° No. IK715— Exemption, you should become subje 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 PERMIT No. LOT 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 I 1;!: C{�- CHARGES ness and Professions Code, and my license is in full force and CONNECTION CHARGE FEE effect. CONTRACTOR License Number Lic.Class ADDRESS REIMBURSEMENT FEE Contractor Pate DISTRICT NO. GROUP MAP PR E' BY 0 LIC CITY TEL.NO. BK PG O . J. 1 ' El STATE I am exempt under Sec. of the L.A.Co. LICENSE No. CLASS ! �� Plumbing Code and/or Sec. of the NO DESCRIPTION OF WORK FEE 0 FINAL HOUSE SEWER CONNECTING TO DATE ' 1 VALIDATIONu B. 8 P. Code for the following reason PUBLIC SEWER G e U SEPTIC TANK,SEEPAGE PIT OR FIN H PITS AND/OR DRAINFIELD BY f Date HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 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, BUisnes5 and Pro- ALTER,REPAIR OR ABANDON HOUSE fe5sion5 Code): SEWER OR DISPOSAL SYSTEM (�8T 9 A ❑ 1, as owner of the property,or my employees with wages as # - - - - 1 0 their sole compensation, will do the work and the structure is not intended or offered for sale Section 7044, Business ( 1 - 1,50 and Professions Code). OWNERS Permit $ '':�(� ❑ 1, as owner of the property,am exclusively contracting with AUTHORIZATION FTOTAL FEE - - - f^ 1,5 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. 1 /1 5 1 —8 4 CONSTRUCTION LENDING AGENCY ► iA 6 J J 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 OROWNERS AGENT issued (Sec. 3097, Civ. C.). ADDRESS ' Lender's Name Lender's Address 1 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 on the above-mentioned property for inspection purposes. Signatur Permittee Date SEE REVERSE FOR EXPLANATORY LANGUAGE