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1093A (5)
� -:::.-. .,,..., ,:,,. �.,.....:, . .._ .�.. _ _._ ,. . __ � 76A642D � CE608(REV.6/781 I/79 AP'F�L.C��4,T1�tlI FCaR�P��RIVt I`I' �s s�w�� - s�w��� ����c���� COUNTY OF LOS AN�ELES �UIL�IIVCr AiVD SAFETY FOR APPLiCAhlT'�(9 PILL IN o�srR�cT No. �RQ�1P MAP PROCESSE'�BV �] �(f.�f BK �g G �•� BUILOING �� (-- ��A� . . . ...i/ �) s� �.Ps ,.�� ��'�,� ,�`�'"' l AQDRE55 y4,e,� 4f�, ,1 LOGALITY '_�,�J - � 4.:J''" ____ �AIVIdECTBON DATA � NEAREST � j/ J STATION ,..,.L.}t....4� DEP7H 'r� CROSS ST. _ �: F ��t -� ^'��ti'� �K•��.� �� D � UPPER MANHQLEREFERENGE LOWE OWNER � � TYPE OF CONNECTICDN LENGTH FROM MAIL ,���� =-�C� e Y. CURB P.L. M.L.TOP.L. APDRE55 �i- r CO.IMP.NO. JOBNO, a.�..dCr( GITY TEL.IVO. "�J�.�� LEGAL i'J TRUNdC PERMCT NO. ROAD PERMIT NO. DESCRIPTION LOT NO. �17� �� AFF1DAViT WAIVER EaSEMEN' RECORD.WSTR.NO. DATE BLOCK TRACT - NO.OF 6LDGS. �. 51ZE OF LOT NbW DN LOT � NWV.OR ST.WIDENING � � � � �� � - USE OF BUI�DINGS S7ATE ENC.RDACHMF_NT PERMIT NO. CONTRACTOA INDUSTRIAL - WAISTE APPRQVAL ADDRESS �( GHARGES CONNFCTION CHARGE FEE CITY TEL.NO. ��.-� � �- L CAENSE NCa.���1+�� GLASS (,,,.^"'��� REIM6UR5EMENT FEE � �..c-oJ- �,d' NO. DESCF21pTION OF WOF2K FEE qpp�py,��,S DAT EGTOR' I NA7URE � HOUSE SE'WER CONNECTING TO t py � � PU9LiC SEWER &` .� SEPTIC TANK.SEEPAGE PIT OR NEW Fi0U5E SEWER PITSAND/ORORAINFIE�D � CONNECTADDITIONAL � � HOUSE SEWER GONNEGTING TO BUILDtNG OR W062K PRIVATE[J15P05ALSYSTEM 5EPTIG TANK,SEEP,PI7151 � CONNECY ApDITkO1VAL�6lDG.OR AND/OR DRAINFIELD � WORKTOF-0OUSESEWER � � .mo OVER�LOW SEEPAGE PIT,ORA(NFIF..LI'? (�ESSPDOL �] DRYINELL EXTN..CESSPpOL.DRVWELL.MANHqI_E � � ALYER,REPAIR ORA9ANOqN HOUSE� �� - dL7ER,REPAIR,S�WER OR SEWER OR OISPOSAL SVSTEM $EWAGE pISPQSAL SYSTEM - ; 615Cd14NECT PLUG AND ' ABANDQNFIOUS65EWER BACKFILL SEPTIC 7AfJKS Q �yy��R+§ Permil � �, SEEP.PIT1Si[,] cFssaoo�s'_7 Al8T9i63131Z�TION TOTAL FEET (�� V.�IIDATIC36V : I HAVE AT THIS DATE A CONTRAGT WITH THE MEREIN NAMED CON- TRACTOR TO dONNECT THE ABOVE pE5CRIBED EXIST(IVG DWFLi_INC , y r r.� �;_ �` TO THE PU6LIC SEWER = 1 �y y � /) ' SIGNEDTI-115 / DAYOF ` 7� � , � owNeROR r fi, w ° '� i /JWNEFi5 AGEN7 � - � ADDRE55_ � '�d '"a�.•�',�� C1. i„}�^ . i HEREBY AGKNOWIEDGE THAT f HAVE READ THIS APPLICATION / p, � AND S7ATE THAT THE ABOVE IS CORREG7 AND AG12EE TO CbMPLY 9 `",�,g'� C.4�l;�4J 4i - WITH ALL GOUtYTY ORDINANGES AND STATE LAWS -IdEGULATIfJG PLUMBING AND SEWERS. 9 1 HEREBY GERTIFV THAT I AM PROPE�LY REGISTEqEO ANO/OR �,,� � { ``� '�+'^(�j�Lj LICENSED hS REOUIRED BY LQS ANGELES GOUNTY AND STA7E OF CALIFORNIP�OR THAT I AM THE LEGAL pWNEK!tlF,AND INTENb TO RE- SIDE IN.THF AB�VE�ESGRI6ED RESIDENTIAI.PROPERTY, r'^ SIGNATURE OF PERMITTEE _����� - :.,...,.;n+.�+.� . . . , . . . . . . . , : �����R��A�����5� , �a��������5����a�be�a�§���� 1. ii�l�;�,'��'E fa;i.�. �iUI�.Qlz�1C',� C7�! PRCIPERTY. ....._��.._.,.�.,.�...._.�.. — ---- 2. I�it�l{;;�,TE x^-,i�!€s s?I��1!�4v�iiiei�! S��.td�1",�`E l7i$PCS,�R_ S�(STEP�, irVl'T�i T(E �l�TA��°ES TC7 3UILDfl�•E�S. k ,. /�NC?P��PL"l27�i° Li1�3�S. . .3 �;` t d .. 3.Di�3[�IC�TE S��� t'�F S�P��C TA�°vK-��YiH �s=SE�P- ` . ' . ,4�vE PETtS}-������-��`:��r^;J�L;SP. �..'- L. ; 4. 9�,lI7IC�l E i�C?��'�I�IRE�`�'i�411��*1 �Lt�l-. � ... ,. . , a , ,:�::r, � k.�. 5. li��l�T�����ST���;S iF C��;�ER. ' .. . � - � . . : .. , . A. . 'b` .t.r.,'i t .. �..3.,,.. � -�..�,�M� . , - Y d , .. ,. .. .. � . , .. . �.. ' . e. .. ��,,:: .. . "-:S"�.�'.��. .��.d.� . . , . 1:.,i.,L�b .Y�..}..: ��'.."'s . '� :k'�.` �..�N\."Y'��h:::.. - . ..r .. -....;Y �. . , . . .,...d'�S..i\ �,� ..... ' � . �.. � ,_ . , ' ..... ........ . . �� �.. w .....�_�. . -.. , . �.L. :t.... .. w. STe ALLEY R/'�a' � - � ��� � FlEL�N�T�S �.T.�. —--- ��____.� � :�;..,. �___�__,___ ._._____.________._ _� � � .�.