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HomeMy WebLinkAbout1095A (5) � ,..:,.�. �: :..,,..,-:. ..,,.. ....,.....:., ._:.....,.. .. �..._...:;. . .. :�.,:. .. . . .. :. .:. � .. . . . .. . , . . . . � 76A642D CE808(REV.6/78)1/79 /� ��/ �� /\����j �/",� -������ . . ... .. .. . . . . OOS �.,�, l.. eI°'1 1'eU '�A .�'a���R — .S. ����� �I���e�J.�N.,. COUNTY C1F LOS ANGELES B9Jil�inlG�ND SAFETY FO�04PPLICA�T T��ILL�IN � DISTftICTNO. G UP MAP PROCESSED�Y �. , � ,�,1 �"'�' � PG � BUI4DING r ADDRESS � ;�..� CAtdNECTIQN pATA IOCALITY J NEARE57 ` � 57ATIDN ,�,�"J, �,/ ❑EPTH ( CRO55 5T. eSv� '� •� � r � UPPER � , MANHGILE qEFSRENCE L¢ Qw OWNER C;� r 7YPE OF GONNECTION� LENG7H FROM MAIL ' � Y. CURB M.L.TOP.L. ADDRE55��! � � �" GO.IMP.Nb. JOB NO. ���� CITY TEL.NO. �i "���� LEGAL TRt1NK PERMIT NO. ROAD PERMIT NO. �ESGRIPTION LOTNO. �,��^[� ,�r� AFFIpAVIT WAIVER EASEMEN7 RECORD.IN5TR.NO. OATE BLOGK TRACT _");)�j'�c � i.s� NO.OF BLDG5. - SIZE OF�OT NOW ON LOT HWV.OR ST.WI�ENING � � USE 4F 6UILDINGS � STATE ENCROACHMENT P�RMI7 MO. CpNTRAGTOR �NqUSTRIAL WASTE APPPiOVAL t ADDRE55 � •f GHARGES CITY TEL.NO. ...-� �� GONNECTtONCHARCaE FEE e°A` STA7E ��+ ✓ LIG, f!'� /7 REIMBURSEMENTFEE � LICEN5E NO. � CLA55 ( f� ,6� NO. DESCRIPTION QP WORK FEE qpp�p`/��5 DATE IN T ' ' � , HOUSESEWERGONNECTING'ftl „ .A'f � PU9LIC SEWER `� � SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER �}.. PITS AND/OR DRAINFIELD CONIVECT AODITIONAL p,$p HOUSE SEWER CONfNECTING TO BUILDING OR WORK ��,. PRIVATE DISPOSAL SYSTEM � g¢8 SEPTIC TANK.SEEP.PITI51 I � CONiVEGTAp�ITIONALBLOCa.OR ANp/ORDRAIfdFI�Lp ' WORK 70 HOUSE SEWER '�' OVERFLOW SEEPAGE PIT,DRAINPiELD GESSPOOL ❑ DRYWELL❑ EXTN..CSSSPOOL,DRYWELL,MANHOLE ALTER,REPAIRORABANDON�HOUSE�� ALTER,REPAIR.SEWER OF2 SEWER OR DfSPOSAL SYSTEM SEWAGE DISPpSALSYS7EM ' � ' ' DI5CONNECT PLUG ANO -----•- ABANDCAN HOUSE SEWER BACKFILLSE^P71GTANKS[] oY�6VG'R�7' Permit $ �� SEEP,PIT�S��J CESSPOOLS._j f 4�iJTHOR9Z/>T60N TOTAL FEE ,g►� V�ILIDATION I HAVE AT THIS OATE A GON7RACT WI7H THE HEREIN tdAMED CON- TRACTOR TO CONNECT THE A60VE DESCRIBEp EXISYING DWELLING r. '� /; �"1 4".; (�4 70 THE PUBLIC SEWER, ,-�/^�� "- e� 7 � ; 51GNEDTHIS � _,.DAYOF.� /� .s(,.�_5� ��� �� � � � ;Q � � .� QWNER OR � � � � �pWNIERS AGENT �AODRE55 ��� '���� � i��'' ' . ,�,; I NEREBV ACKNOW4EDGE THAT 1�HAVE REAp TFiI$APPLIGATION �@ r� �iD, �.��j`�,��` � ' . . :4ND STATE THAT 7HE ABQVE IS CORRECT AND AGREE 70 COMPLY ' " '�YVI7H ALL COUNTY ORDINANCES AND STA7E LAM/5 REGULAYING "PLUMBINGANDSEWERS. . �t di-"; (��,`�r^., 'ryy I HEREBY GERYIFY THAT I AM PROPERLY REGISTERED AND/OR v �- y ti.t � � LICENSED AS RE(]UIRED BV L�SS ANGELES CDUNTV AND STATE OF ��CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,i4IJD INTEND 70 RE- 'SIDE IPd.THE A60VE DESCRIBED RESIDENTY � RO!'ER'fY. r ^SIGNATURE ' � �f ��OF PERMITTEE Z`"�-""� �����������i���i5� ������������������� 1. 3�L�i�,�7� F�L!_ �?U!LD!��d�� C�! FRC��c^�1''r'. � rn.� 2. li�lF�l�fa�'� F��i� �if�t1EC�1Si�![V 5�.`J�lAvE ?:iS°��,�t�L � ;�°fSiCtar'� V'�diT}-� i!c I�fSTf�fil�E;� T� BlJli 1.7;TtiG5 � , > �, . y ` � /�,i�3G PRC?P�.�;�'Lt�IE:. } , , _. �, _, ,.. � ,�" �`�:` �'��. 3.IN�E��a3E SP�� ��=SFP�iC;iA�K-i��l���N C�r SE�?- � _ N,,,�� `�,"� AGE piT(:�f -Sf�E C���ESS;'1��1.15}. ,'�t� _ �; `;,. � ,*:- � 4. l�t31�1aTE�*9�R�hi C�IRE�T9€���J�; PLC3T. � � �' �'�a ` s,.. �,:��`�,.�,. �.� ,�, a.�-�r , .. '`�;� i;..` � „ .�w i, ,.`a 3 ;v.� 5. li�sJi�l1���C�Tc�S�'�2C�i'S{F C�(?ti�f<. y `. _.. ''.a, �.t—• i:�LL,�: . `�r"�,:�a,�� '�,� � ,. � , �. 3 . .a .., .... - � - � � ... ._.. 4 i.. �3 S � +, ..�.�a ��` . �T?q, ...�.3� a»..°''1�' , or . ...�. .. -�'�4`�, .t. ' ..+ � JC .J . , . .n � • . ".✓ ._ Y'.. x_� t.....: . � ST.�!t LE4°Ri°+�d F�EL��iC?TES �� - � . . ' 4.ry,.r. wy;,, .a e �; . .. . �..e......e..�a_.�_ _.... L \..� «�+...r..:�'Y.,M•e•+. ' :-K P T _. - _ , .:y,+ M,s..�emo..m.�.e,...i��•--�...m�s.�..v�..s....� ...w.� .e. '—e...._....�...�.<.e.�s..,...».�...�_.....d............m.,.e.....e�...�. ...�....�...a.....,...�...n �..��. „ �. '�, �..:? ,.�;