HomeMy Public PortalAbout9653 WOOLLEY ST_Sewer__ 76AE66B 9:2.5.Y
S APPLI;CA' ION FOR PERMIT 1
&E•EEi
DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGIN8SR ADDR1rSS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
_...._-_..._ u_.,_a.�..._-�_..R._....�
FOR APPLICANT TO FILL IN NEAREST.
_. cxOss sr
LEGAL � Z�'�r�� � � ��, , _... _"..__.._...m._ _ __-.....__�._
DESCR PTION _LOT NO. �y--- ,� "'" OWNER
BLOCK t TRACT ; "'� ,�' MAIL -
- ADDRESS
.i � MO,OF PLDGS. - - -
SIZE OF LOT ...- NOW ON LOT ,�
�..__. _ CITY TEL, N0.
USE OF
BUILDINGS� .._.. ,..�. DISTRICT NO. GROUP i MAP
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY —. _ .� TEL. NO STATION -DEPTH
[� STAiE MANHOLE REFERENCE
REGISTRATION N.O. n COUNTY __ UPPER ,,*' LOtNER_
TYPE OF CONNECTI LENGTH FROMy,a''-
NO. I� DESCRIPTION OF WORK FEE - _Y�. CURB P. bt.L, TO P.L�_._�
HOUSE SE'sVER CONNECTING TO
PUBLIC SEWER_ M $ 3.50
HOUSE.SEN FR CONNECTING TO *'
jR.YATE DIS -O$AL SYSTEM 1,00 --
CONNECT ADDITIONAL BLDG. OR —.-- - "�
WORK TO HOUSE SEWER 1.00_' CO. IMP. NO. jaB$.N0.
L
AFTER OR REPAIR EXISTING s
S @ER. OR DISPOSAL SYSTEM 1.00 I j 'TRUNK PERMIT NO. ROAD RMIT NO.
I DI CONN CT AND ABANDON SEWER
AND/OR_DISPOSAL SYSTEM_ 1.00 I STATE ENCROAC#iN,ENT
- PERMIT N0, Z
SEPTIC TANK, sEEPACE I-9Y OR -- - -
PITS AND/OR DRAIN IELD ? 00 I^ j INDUSTRIAL `G.
I CESSPOOL- DRYWELL I- WASTE APPRGVA -11
`4.
SPECIAL CONDITIONS ONLY __ 2,00 I ( 1 CHARGES
'- -"-"--- CONNECTION CHARGE FEE
T!
OWNER'S PERMIT �.-_I 1 If� a0
AUTHORIZATION - TOTAL FEE I f-- REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR`S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
NEW HOUSE SEWER -
SIGNED-'i-il5 DAY OF 19__-- - � :--- . — _--_ -----
OWNER OR CONNECT.ADDITIONAL
OWNERS AGENT BUILDING OR WORK
.-CPTIC TANK SEEP; PITS
AND/OR DRAINFfEL]"
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL CI DRYWELL[]
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 DISP05 AL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR --
L#CENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE _ABANDON HOUSE SEWER_ _ -
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP, PITS) 0 CESSPOOLS 0
SIGNIATURE
OF PERMIT.LEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY BY
DEPUTY °` DEPUTY
BY BY
;0 DEPUTY DEPUTY
WORKERS' COMPENSATION DECLARATION 2d-(Dai q
� I her.S y asDPW Pi'9
�6i,nl that I have a certificate of consent to elf 70-oo5i
.4,erre *a certificate of Workers' Compensation Insurance, or « s
Pall<, 'Zj .amaa3 °-` --- c.< APPLICATION FOR PERMIT
.--- y
j_._ .':ernfled copy .s hereby furnished
- SEWER .- SEWAGE DISPOSAL
[ Certified copy is filed with the count, building inspection COUNTY OF LOS ANGELES BUILDING AND SAFETY
departm nt
ate v7 -Appli;,a"t----�`-, Y�- .�''�7r 4FNEAREST
FOR APPLICANT TO FILL IN CONNECTION DATA
.—._—`
CERTIFICATE OF EXEMPTION FROM WORKERS' s�
COMPENSATION INSURANCE f6� snTloN DEPTH
This section need not be completed If The work involved by the � UPPER
k"" j�,_. MANi10dE REFLrtENCE
permit Is for one hundred do!lars ($100)or less 1 �" LOWER
TAPE C?r CONNECioJN Lt-NGT,'fROM
certify that in the performance of the work for which this dti"f culla P E ML ro P E
permit is issued, I shall not employ any person In any manner LFC_`AL I,, NO
o as to become subject to the Workers' Compensation Laws- DCSt;RMTION LOT NO CO Irma NO )oe NO
E1t.00K TRACT !PN+ PERty+,IT NO ROAD PER.y.iT NO
Ute _APPlicant�
NOTICE TO APPLICANT_ If, after makingthis Certificate of M E-SSOr; Aii.IDAv�IT wnrdER EASEMENT RECURo INFiTR NO PATE
MAP 600K PA.' FAN.OEL
f,em tion, you should become subject to the Workers' _
p Y N:J.JF fi:_OGF.
I-mpensntion provisions of the Labor code, you mus! forthwith NOW ori I c ORST W(DENiNC,
_omply with such provisions or This permit shall be deem=ed USE OF _
revoked. euli nINGS 'ATE ENCROACHMENT !�j✓€"
LICENSED CONTRACTORS DECLARATION / _ / Prkrnl No G{C s
I-,ereb affirm that I am licensed under Provisions of Chapter c°vNEFa ��`! t [' E .- �r `� }
Y P p ✓ +�t e
`> +;coh mrnencing with Section 7000) of Division 3 of the BusMa'IL p Gs CHARGES and Professions Code, and m�license Is in full force and ADDRESS J
9 Ofect. CONNECTION CAR E FEE
ly9 - //`j� GfTv f C[ TEL NG. � �7 r7
CiccenniraeCtNour mbe_r � ,Lic Class-
RF.M5J RSE MENi FEE
CONTRAGIR %U. !
` DI iCT NO GRC`UP MAP PROCESSED BY
ADDRESS C- -fig „�' BK PG
4 I at, "empt under Sec. of the l.A-CoEL
clrr < ✓ TEL uo c:_ ..f -s -c.zt O
Plumbing Codeand'or Sec _ —ofthe STATEy LIC E;NAS. U
tiCENSENO 4Y'( �,��� CLASS DATE ] �' VALIDATION
B !S P. Code for the following reason NO. 1 DESCRIPTION OF WORK EEE
N l E SEA :F. FINAL f-
�T----_�D+a�te._.__,--_ ._. Pu5tC SE:V✓
..EP r;ANK EFPACrp PI,OR,
rT AND P .'.
RAFIE U LL
OWNER-BUILDER DECLARATION HOUSESEWER eC NG T� �
PR JATE DISPOSAL
Al.v,TEM -
I hereby affirm that I am exempt from the Contractor's license CONNECT An CNA,B,JG ell P, - `
Law for the foilowina reason ISecton 7031.5, B4:ISneSS and Pro- WORK To Hcu)St SEWER
fessians LOCIE VERF;C'W SEEPAG PT RA NFIF;C f
_ ) EXT d CESSPOOL DRYWELL MANHOiE _
A TER.REPAR TR AnntJrlN i+C7!�SF �"' ',"( ,t..#'.rh wfF��r
as owner of the property.or my employees with wages as ,E V OR .Sa.S PSTF `
their sole corm ensotion, will do the, work and the structure 4, Rx`
is not Intended or offered for sale (Section 7044, Business
and Professions Code).
1. as owner of the pruPertt,am exclusively contra<ting with
licensed contractors to construct the project (Section 7044, OWNER'S Permit $ ,'�? ; .7
Business and Professions Code). AUTHORIZATION TOTAL FEE f: m
CONSTRUCTION LENDING AGENCY I r,AvF
i. AT TW, -..1:.V 4,CT WITH THE ERFI.. NAMED Tf)
hereby affirm that 1 ere s a constrvCtion lending cigency ^lair HE sF r ,e,_Rr E,ExIST,V VF.�ic, . THE PLS, a+afa r
for theperformance cif the work for which this; pe—irt is " � �
Issued (Sec" 3097: il C ;. SIG-Nils THIS-- DAY Or ,9
c 11NER t
lender's gq 4JName _ _ - kA
wNERs A;EN -�-
�tY, Lender's A dressADORESS
I certify that I hoe -ead this application and state that the
if,
above information is correct. I agree to comply with all County
ordinances and State laws regulating PluMbing and Sewers,
anti here,y authorize representatives of this County to enter
upon th ovum_ �ned ro;�erty f r nspecii�n pl.rrpcses.
Sign utr of'Permlttee Dote SEE REVERSE FOR EXPLANATORY LANGUAGE