HomeMy WebLinkAbout0 (16) APPLICATIONFOR PERMIT
cE SEWER- SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO PILL IN % o[TIICTlo. cgwF LR MAP PIOCESSES EY
BUAooaR.OING
BE
CONNECTION DATA
N"FIRST j +�'� `•^-� STATION BERN
I�. GROSB ST. .. '/ - VPPER
[[�� MANHOLE REFERENCE LOWSp
OWNER L..�/Jf/LJ `� TYPE OF LENGTH FROM
1J Imo` Y. CUR! PL. ML.TO P.L
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CO.OMP.NO, JOB NO.
' LBQ TRUNK PERMIT NO- ROAD PERMN'NO.
DESCRIPTION LOTNO.
ARPIDAVIT WAIVER EASEMENT gEGORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF SLOGS.
SIZE OF LOT NOW ON LOT NWY.Op ST.w10[NIN6
USE OF - STATEENCROACHMENT
BUILDIN65 PERMrt NO.
+� INDUSTRIAL
GONTRJkCTOR •. {I• WASTE APPROVAL
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ADORESSU? • �• }�
' .«� CONNECTION CHARGE PEE A
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STATE +1 LK. .u�r ds' REIMbURSEMINT PE!
LKBN$E NO. T CLASS 7 Iy
NO. OESCRI"Of4 Of WORK FEE APPROVALS DATE N}PECTOR'S SIGNATURE
LL
�( HOUSE SEWERCDNN[GT{N6 TO .r
PUBLIC SEWCR HOW HGU$[SlWERcc
$BRIG TALAR.9[LPAGE PIT OR
PITSANO/OR DRAiNRIELD CONNECT AOON"O w1
f - HOUSE SEWER CONNLCTING TO BUILDING OR WORK C7
PRIVATE DISPOSAL SYSTE M .ERIC TANK,BEEP,P1TtSI 6
G - CONNECTACCHTiONAL 614G.OR -f r AND/Op ORAINPOELO t
I' WORK TO MOUS-BEWEp `G
OVERPLOWSEEPA E PIT.ORAINFIEI.O CESSPOOL.❑ ORYWlLL❑ W
EXTN..GESSPOOI.ORYW[LL MANHOLE ~
ALTER.REPAIR OR ABANDON MOUSE ALTEp.REPAIR.SE W ER OR
S!W!p OR DISPOSAL SYSTlM SEW AGE DISPOSAL SYSTEM
DISCONNECT
P{.UG AAE3
NDON HOUSE SlWER
EAGKfILLSERiC TANK}Q
Permit ! I
SEE,'ms) CESSPOOLS[�
OWNER'S VALIDATION
i AUTHORIZATION TOTAL FEE
1HAVE AT THIS OATE A CONTRACT WITH THE HEREIN NAMEO CON.
TRACTOR TOCONN.Cl THE ABOVE bESCRIblO
TOT O THiC SE-,J
SIGNED THIS �DAY CI 1
( OWNER
OWNERS AGENT
ADORE 55
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AOREE TO COMPLY - IA �+•E`�'� �
WITH AIL COVNTY ORDINANCES AND STATE LAWS REGULATING
PLVM IIRBSY CERTIFY THAT 1 AM PROP-1 REGISTSREO AND/OR
LICENSED AS REQUIRED BT LOS ANGlLES COUNTY ANO STATE OF
C CALlROiENiA OR THAT i AM THE LEOAL OWNS-OP-ANDINTENOTORE-
$109IN.THE ABOVE OESCRID%P RESIOENT-0,S{O►EMy.
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