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HomeMy WebLinkAbout1087A i � _ . _ F� 76A642D � CE808(REV.6!7817/79 /0 �L��i� /��'/"g,R1 C�'"1� E����/11T �5 B'•1 I�" ! t"1 4.,/1\I [-"4r.�I" If' . i V�! � �E1f11E�3 - SEdlliACaE DI�Pt�,�AL COUPlTY OF LOS ANGELES 8�19.¢69�G AND SAFETY FOR APPLICJ�NT T4D FILL IN �ISTRICT NO. dUP MHP PROCESSEo BV BUILDING �/p� � �.y( *�� ,G[ � /J G ADDRESS ,��[„ —l �EA� 0 � `""�'r' �Of41�8ECT101V DATA LOCALITV / � �� NEAREST '� STATIQtd �/ DEPTN CROSS ST. r �°� l7/� /�B,ry q�, ,�/ MANHOLERF_FERENGE ' � '�� UPPER OWNER �/�r*�./L,C1 l.j E TYPE OF GOfNNEC710N LENGTH FRpM MA�L m j� ' Y. CURB .L. M.L.TO P.L. ADDRESS �.1 � P.C.NO. �� � � �� CKD.IMP.NO. JOB NO. CITY TEL.NO. . LEGAL TRUNKPERMIYNO. ROADPERMITNO. DESCRIPTION LOT NO. �*-'7^�� ,r �^+ AFFiDAV1T WANER �EASEMENT RECORD.INSTR.NO. DATE BLQCK TRACT �°S�C Lr, n f 1 F✓ NO.OF SL�GS. SIZE OF LOT NOW ON lOT HWV.OR ST.WIDENlNG USE OF OUILDINGS STATE ENCRCIACHMENT * PERMIT NO. � GONTRACTOKi �_��.� � � _ ��:y� WASTE RPPRCdVAL �'� '� ' CHARGES ADDRE55 .� ,� [,�� GTY �.1/j�, _ TEL.NO. .� G,J �� CONNECTION GHARGE FEE �° STATE +° LIC. ,�y REIMBURS6MENTPEE � LICENSE NO.�. CLA$S �.^'— (� NO. DESCRIPTION OF WORK FEE ��P���I��S ATE INS G OR'S I �IVATURE � , HOUSE SEWERCONNECTING 70 }� � PUBLIC SEWER Pf C� SEPTIGTANK,SEEPAGEPI70R NEWHOUSESEWER Q�. � $�u � PITS AkVD/OR DRAINFIELD � - CONNECT ADDITIDNAL f� HOUSE SEWER CONNECTING TO �UILDING OR WORK � �, PRIVATE DISPOSAL SYSTEM - ($Q GONNECT ADOITIONAL BLDG.OR S�F'T�C TANK,SEEP.PITIS) � WORK 70 HOUSE SEWER ANp/OR DRAINFIE40 ,�,� OVERFLOW SEEPAGE PIT,DRAINFIELI3 CESSPOOL ❑ ORYWE4L[] EXTN..CESSPOOL.DRYWELL,MANHOLE AL7ER,REPAIRORABANDON HOUSE ALTER,REPAIR.SEWEROR SEWER OR�ISPOSAL SVSTEM $EWAGE DlSPOSAL SYSTEM RISCONNECT P4UG AND ABANDON HOUSE$EWER BACKRLL SEPTlCTANKS L,) �L���CR�C Permlr SEEP,PITIS)❑ CES5POOlS❑ v� c � � AU�H�RIZQ,TIO[rf TOTAL FEE �ro lOe4LIDATION I HAVE AT THIS DATE A GONTRACT WITH THE HEREIN AMED C4N- TRACTORTO CONNECTTHE ABOVE�DESCRIBED E7CISTING-DWELLING ' ?-� h n r � . TOTHE PUBI.IC SE� ; �s Ci SIGNEDTHIS DAYO _ _19� �.� � � .�.� � OWNER OR � OWNERS AGENT ! ry (� �^�, A�DRESS �'r�� � r `, ��lJ. . I HEREBV ACKNQWLEDGE THAT I HAV� READ THIS�APPLICATION � ,;. ; ,` � /^; . AND STATE THAT THE ABCIVE IS CORR6CT AND AGREE 70 COMPLY .. . �`�'�.P��.�� WITH ALL CQUNTV ORpINANCES AN6 S7ATE�LAWS REGULATING PLUMBING AND SEWERS. ' / (} 1 HEREBY CERTIFY THAT I AM PROPERt_Y REGISTEREO AND/OR (,�` (7; � ��'(.;��{ � LICENSED A.S REQUIRED BY LQS ANGELES GOUNTY AND S7ATE OF GAIIFORNIA OR THAT I AM THE LEGAL OWNE F,AND INTEND TO RE- SIDE IN,THE A80VE� ESCRIBED RESIOEN7pAL ROPERTY. r SIGNATURE �, OF PERMITfEE ( �����������s�r t��� ���;������������������ . i. i������r� a��_ ��EL�ira�s car•� �e��E,���. �-._.__ � 2. ii�D1C�TF ��:�� �orvt��S1.Cz!� �E1'��:��� �ESP��r��. S`;S�EN`� ��;T'r# 3!� �lST��.'CE`�' �'� �'�°u°�L�I{�!`aS :, � �I'�I�PR�i'��?T�f Lti�L�s. . ,, : :i f �..1.�',�. , ' � 3. Il�f�i��s'� �I�� �s= �cP��ir TA,€`!�-L�CF�H QF SEEP• �1��PiTIS! -�,�L����:�aSP��7!mIS�, ` ' . . - . � � ,.,� 4, 1��1�AT��S�?RTi� C?I�EeTl�!�!C`f� PLCJ7. � . .�� �. ., .:: , � .... s .�,:°; . _ ;:3 . � 5. !!ll�i�t"�i�°u��i—IS7RE��'`,�"EF�4�t�tJEn. : � : . , �. �., � ,.' : . ., �>9: . , , . ; � , , ,.. s:�.:�: , . a�- ��- - . . , . .. , _; , _. < . ... STe�,Ll.EY F/�J FIEL�f�l�?TES � �..� .. � � �.;.�_:.,,� .�..,- � -,,