HomeMy Public PortalAbout4832 FIESTA AVE_Sewer_1/11/2016_COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 1601110005
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID:
JTR: 14647 LT: 3
(ASSESSOR INFORMATION NUMBER:
18590-017-009
1
(TENANT:
OWNER:
COBB, LARRY
4832 FIESTA AV
TEMP 917803814
(APPLICANT:
ISMYHTE, BRUCE
13801 LANAWEE AVENUE
ICULVER CITY CA 90232
I
I
ICONTRACTOR:
MIKE DIAMOND PLUMBING HEATING AND A
13801 LENAWEE AVE.
ICULVER CITY, CA 90232
1ARCHITECT OR ENGINEER:
SEWER MAP BOOK: PAGE:
TEL. NO:
(909) 988 -8151 -
TEL. NO:
(310) 838 -0408 -
TEL. NO:
(310) 838 -0408 -
LIC. NO
399170036
TEL. NO:
LIC. NO:
PERMIT EXPIRES 180 DAYS IF
1) WORK DOES NOT COMMENCE, OR
2) WORK IS SUSPENDED OR ABANDONED, OR
3) FAILS TO OBTAIN CODE REQUIRED INSPECTION
ISEWER / SEPTIC: SEWER I BUILDING ADDRESS: I
(EXIST OCC GRP: 1 4832 FIESTA AV I
IBLDGS. NOW ON LOT: TEMP CA 917803814
ICONNECTION TYPE: I NEAREST CROSS STREET: LOWER AZUSA
(ORIGINATION: I THOMAS PAGE: 597 GRID: A5 LOCALITY: TEMPLE CITY CAI
LENGTH ML TO PL: STATION: DEPTH: 1 I
IMANHOLE REFERENCE: UPPER/LOWER: (ISSUED ON: PROCESSED BY:
1 101/11/16 SR
1COUNTY IMPROVEMENT NUMBER:
IPLAN CHECK NUMBER:
IJOB NUMBER:
ITRUNK PERMIT NUMBER:
IROAD PERMIT NUMBER:
IAFFADAVIT: NO
WAIVER: NO
JEASEMENT: NO
RECORD INSTRUMENT NBR: RECORD DATE:
HIGHWAY/STREET WIDENING:
STATE ENCROACHMENT PERMIT NUMBER:
FEES PAID
(FINAL ATE FINA B CODE:
I D
IDESC TI ff OF ORK
IINSTALL A NEW 4" CLEAN OUT ON SEWER LINE IN THE BACK OF
(HOUSE
SPECIAL CONDITIONS:
APPROVALS DATE INSPECTOR SIGNATURE
FEE DESCRIPTION: QUANTITY: UOM: AMOUNT:INEW HOUSE SEWER
O1 PERMIT ISSUANCE FEE 34.40 ICONNECT ADDITIONAL 1 1
15 ALT/REP HOUSE SEWER 1.00 EAC 37.70 IBUILDING OR WORK I I
TOTAL FEES 72.10 1 I I
6j)I SEPTIC TANK, SEEPAGE PIT 1 1
i AND/OR DRAIN FIELD
L �
h CIDRYWELL
(0 L'AfZ � o L�-� (ALTER REPAIR SEWER OR I I
* ADDITIONAL DATA ON FILE
REPORT ID: DPR266
ROUTE TO : BS0508
�ISEWAGE AL SYSTEM jrtq
I DISCONNECT PLUG AND �I J
(ABANDON HOUSE SEWER I I
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IBACKFILL SEPTIC TANKS
ISEEP. PIT _ CESSPOOL _
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IGRAYWATER SYSTEM I I
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OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I JOB ADDRESS
I hereby affirm under penalty of perjury that I am exempt from
the Contractors' State License Law for the reason(s) indicated
below by the checkmark(s) I have placed next to the applicable
item(s) (Section 7031.5, Business and Professions Code): Any
city or county that requires a permit to construct, alter, improve,
demolish, or repair any structure, prior to its issuance, also
requires the applicant for the permit to file a signed statement
that he or she Is licensed pursuant to the provisions of the
Contractors' State License Law (Chapter 9 (commencing with
Section 7000) of Division 3 of the Business and Professions
Code) or that he or she is exempt from licensure and the basis
for the alleged exemption. Any violation of Section 7031.5 by
any applicant for a permit subjects the applicant to a civil
penalty of not more than five hundred dollars ($500).):
U I, as owner of the property, or my employees with wages as
their sole compensation, will do (J) all of or U portions of the
work, and the structure is not intended or offered for sale
(Section 7044, Business and Professions Code: The
Contractors' State License Law does not apply to an owner of
property who, through employees' or personal effort, builds or
Improves the property, provided that the improvements are not
intended or offered for sale. If, however, the building or
improvement is sold within one year of completion, the Owner -
Builder will have the burden of proving that it was not built or
improved for the purpose of sale.).
U I, as owner of the property, am exclusively contracting with
licensed Contractors to construct the project (Section 7044,
Business and Professions Code: The Contractors' State License
Law does not apply to an owner of property who builds or
improves thereon, and who contracts for the projects with a
licensed Contrbftor pursuant.to the Contractors' State License
Law).
U I am exempt from licensure under the Contractors' State
License Law for the following reason:
By my signature below I acknowledge that, except for
personal residence in whicf I must have. resided for at I st
one year prior) to completion of the improvements covere by
this permit, I cgnnot legally sell a structure that 1 have built
er-builder Ia an
ownf it has not been constructed in its entirety by
licensed contractors. I understand that a copy of the applicable
law, Section 7044 of'the Business and Professions Code, is
available upon request when this application is submitted or at
the following Web site: httD://www.leainfo.ca.aov/celaw.htmi,
Date:
Signature of Property Owner or Authorized Agent
I hereby affirm under penalty of perjury that I am licensed under
provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of a Business and Professions Code, and my
license is In f deffect.
Aicennse /a License No.
JLDate �v / Contractor Sig ture
ORKERS' COMP ION DECLATION
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION
COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN
EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO
ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION
TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED
FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND
ATTORNEY'S FEES.
I hereby affirm under penalty of perjury one of the following
declarations:
_I have and will maintain a certificate of consent to self -
insure for workers' compensation, issued by the Director of
Industrial Relations as provided for by Section 3700 of the
Labor Code, for the performance of the work for which this permit
is issued.
Policy No.
I have and will maintain workers' compensation
Insurance, as required by Section 3700 of the Labor Code, for
the performance of the work for which this permit is issued. My
workers' compensation insurance carrier and policy number are:
Carrier Policy Number Expiration Date
Name of Agent Phone Number
1 certi the perfor ante of the work for which this
pe ' ' Issued, I she not p oy any person in any manner
o as to become sub' ct t workers�subject
s_of
California, and ogre that, If shouthe
workers' compe tion pr Is of Sebor
Code, I shat rthwith co with those p
Sicnature of icant Date
LOBBYIST ORDINANCE CERTIFICATION
Complete this section for permits in
Unincorporated Los Angeles County only
This is to certify that I, as permit applicant, am familiar with the
requirements of Los Angeles County Code Chapter 2.160 at seq.,
(relating to the Los Angeles County Lobbyist Ordinance) and that
all persons acting on behalf of myself compiled and will continue
to comply therewith through the application process.
Applicant (Print Name) Applicant Signature
Company Name Date
LOCALITY
HAZARDOUS MATERIAL DECLARATION
Will the applicant or future building occupant handle a hazardous
material or a mixture containing a hazardous material equal to or
greater than the amount specified on the hazardous materials
information guide?
Yes ❑ No ❑
Will the intended use of the building by the applicant or future
building occupant require a permit for construction or
modification from the South Coast Air Quality Management
District (SCAQMD)? See permitting checklist for guidelines.
Yes ❑ No ❑ %
I
I have read the hazardous materials information guide and the
SCAQMD permitting checklist, I understand my requiremyls
under the Los Angeles County Code Title 2, Chapter 220'
Sections 220.100 through 220.140 concerning hazardous
material reporting and for obtaining a permit from the SCAQMD.
ASBESTOS NOTIFICATION
❑ Notification letter sent to AQMD and/or EPA
❑ I declare that notification of asbestos removal is not
applicable to addressed project.
DECLARATION REGARDING CONSTRUCTION LENDING
AGENCY
I hereby affirm under penalty of perjury that there is a
Construction lending agency for the performance of the work for
which this permit is issued (Section 3097, Civil Code).
Lender's Name
Lenders Address
By my signature below, I certify to;each of the following:
I am the property owner or authorized to act on the
property owners behalf.
I have read this application and the information I have
provided is correct.
I agree to comply with all applicable city and county
ordinances and state laws relating to building
constructjo .
I ut�ze representative of this county to enter the
bove-identified property for inspection purposes.
Signature of Prope er or Authorized Agent
Dat % ��