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Home My Public Portal About5328 Encinita Ave_Sewer_1/20/2015_t . s COUNTY OF LOS ANGELES r DEPARTMENT OF PUBLIC WORKS BUILDING AND SAFETY / LAND DEVELOPMENT LEGAL ID: TR: 11492 LT: 21 BL: A ASSESSOR INFORMATION NUMBER: 8590-001-025 TENANT: OWNER: BOCK ROBERT F;DOROTHY J TRS 5328 ENCINITA AV TEMP 917803114 APPLICANT: RODRIGUEZ, RAFEAL 5457 CRENSHAW BLVD LOS ANGELES CA 90043 CONTRACTOR: ADEE PLG AND HTG 5457 CRENSHAW BLVD LOS ANGELES CA 90043 ARCHITECT OR ENGINEER: I SEWER MAP BOOK: PAGE: I I TEL. NO: (626) 287 -1791 - TEL. NO: (213) 290 -8100 - TEL. NO: (323) 290-8100 LIC. NO 240176 TEL. NO: LIC. NO: TEMPLE CITY # 0508 9701 LAS TUNAS TEMPLE CITY CA 91780 PHONE: (626) 285-0488 EXT: SEWER / SEPTIC: SEWER EXIST OCC GRP: BLDGS. NOW ON LOT: CONNECTION TYPE: ORIGINATION: LENGTH ML TO PL: STATION: DEPTH: MANHOLE REFERENCE: UPPER/LOWER: COUNTY IMPROVEMENT NUMBER: PLAN CHECK NUMBER: JOB NUMBER: TRUNK PERMIT NUMBER: ROAD PERMIT NUMBER: AFFADAVIT: NO WAIVER: NO EASEMENT: NO RECORD INSTRUMENT NBR: RECORD DATE: HIGHWAY/STREET WIDENING: STATE ENCROACHMENT PERMIT NUMBER: FEES PAID FEE DESCRIPTION: QUANTITY: UOM: 01 PERMIT ISSUANCE FEE 15 ALT/REP HOUSE SEWER 1.00 EAC TOTAL FEES �* ADDITIONAL DATA ON FILE REPORT ID: DPR266 ROUTE TO : BS0508 AMOUNT:', 27.80 30.50 58.30 SEWER PERMIT SE 0508 1501200002 BUILDING ADDRESS: 5328 ENCINITA AV TEMP CA 917803114 NEAREST CROSS STREET: THOMAS PAGE: 596 GRID: J4 LOCALITY: TEMPLE CITY CAI ISSUED ON: PROCESSED BY: 01/20/15 SR FINAL DATE FINN, Y: CODE: DE'S'CRIPTION OF WORK INSTLAL 3" CLEAN OUT BELOW RAISED FOUNDATION @ END OF RUN TERMINATING @ CRAWL SPACE SPECIAL CONDITIONS: APPROVALS NEW HOUSE SEWER CONNECT ADDITIONAL BUILDING OR WORK SEPTIC TANK, SEEPAGE PIT AND/OR DRAIN FIELD DRYWELL ALTER, REPAIR, SEWER OR SEWAGE DISPOSAL SYSTEM DISCONNECT PLUG AND ABANDON HOUSE SEWER BACKFILL SEPTIC TANKS SEEP. PIT _ CESSPOOL GRAYWATER SYSTEM I DATE INSPECTOR SIGNATURE OWNER -BUILDER DECLARATION LICENSED CONTRACTOR'S DECLARATION I hereby affirm under penalty of perjury that 1 am exempt from I hereby affirm under penalty of perjury that i am licensed under the Contractors' State License Law for the reason(s) indicated provisions of Chapter 9 (commencing with Section 7000) of below by the checkmark(s) I have placed next to the applicable Division 3 of the Business and Professions Code, and my item(s) (Section 7031.5, Business and Professions Code): Any license is in full force and effect. city or county that requires a permit to construct, alter, improve, C- 3 b g demolish, or repair any structure, prior to its issuance, also ---4—License Class License No. '`�" requires the applicant for the permit to file a signed statement that he or she is licensed pursuant to the of the / / Date I 2 O tSContractor Signature 1JA, provisions _ 7� Contractors' State License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions WORKERS' COMPENSATION dECI ARATIO il Code) or that he or she is exempt from licensure and the basis for the alleged exemption. Any violation of Section 7031.5 by WARNING: FAILURE TO SECURE WORKERS' COMPENSATION any applicant for a permit subjects the applicant to a civil COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN penalty of not more than five hundred dollars ($500).): EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COM U I, as owner of the property, or my employees with wages as their sole compensation, will do (./)) all of or `) 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 Contractor pursuant_.to the Contractors' State License Law). ' (_) I am exemdt from licensure under the Contractors' State License Law for the following reason: By my signature below I acknowledge that, except for my personal residence in which I must have resided for at least one year prior) to completiory of the improvements covered by this permit, I cannot legally sell a structure that I have built as an owner -builder If 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: htto:/Aw .lecinfo.ca.aov/calaw.html. Date: Signature of Property Owner or Authorized Agent AS PROVIDED PENSATION, DAMAGES 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 wor ers' c p ns ' n insurance carr' r and policy nu er ;L,. CaffibF Policy Number Expiration Date �S Name of Agent Phone Number I certify that, in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith com/plly with those provisions Sure Appli do � i U Date r LOBBYIST ORDINANCE CERTIFICATION Complete this section for permits in Unincorporated Las Angeles County only This is to certify that 1, 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 complied and will continue to comply therewith through the application process. Applicant (Print Name) Applicant Signature Company Name Date I. JOB ADDRESS LOCALITY Jill 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 ❑ N o ❑ I have read the hazardous materials information guide and the SCAQMD permitting checklist, I understand my requirements 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 owner's 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 construction. I authorize representatives of this county to enter the above -identified property for inspection purposes. ' S_ture oof`Prope Owoner/o u�thaa/.d,�z\ed Agent