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HomeMy WebLinkAbout1089A „. _, , ,- , � . . . .. I ,: . . , _ . _,r.., . 76A642D � CE 808(REV.6/78;1/>9 ,q P P L[�AT 1�1�I �t�� �”E F�n/[IT �5 ��{ c ��Jf� /''�C ���Y�� " A7�rY/��� �����r/�r7�� COUl�ITY�E LOS AIdGELES BdlII�ING AiVQ SAFETY ' FOR APPLICANT T� FIIL IM ��STR�cT No. � UP MA? PROCESSED BY BUILDING .�i� � _X ..;p5 ��.,r J f� e�� a ADDRE55 .�( a,' �"' �� (/ �r LOCALITtl � �I "¢J P pCBNNECTlOtd DATA NEAREST S � STATION �q u DEPTM CRO55 ST. � ' � yy MAIVHOIEREFERENCE .�f'' ` � LOPER OWNER � (�, l/����_ TVPE OF CONN�CTION � LENGTH FROlN MAIL � y—��.~._, Y. CUR� P.L. M.L.TO P.L. ADDRESS P.C.NO. Q I�"'_rJ 1�" G,�/% / PJ GO.IMP.N0. J06 fdD. �w L.T��J CITY � TEL.NO. f� ( � LEGAL � TqUtVY(PERMITNq. ROApPERMITNO. DESCRIPTION� LOT NO. y'� � AFFIDAVIT WAiV[R EASEMEN7 REGORD.INSTR.NO. DATE BLOCK TRACT L!�°7� NO.OF BI.DGS. — SIZE OF LOT NOW OIV l47 MWY.OR ST.WI�ENING USE OF BUILpINGS � STATE ENCROACHMENT PERMIT NO. CONTRACTOR INI7USTRIAL WASTE APPROVAL /�j ��f i Gh7ARGE5 ADDRESS`,�.. )[/�' _.�,/�.f � ,f '4= F ' �, 1 CONMECTION CHARGE FEE CITY „�,ij�4,� TEL NO. �T��'�J � STATE � LIG. � � R�:IMBURSEMENTFEE � LICENSE NO� GLA55 , NO. D�ESCRIPTION OF WORK FEE �pp�g,�dqag OA7E INS CT 5 SIG ATURE � , HOUSESEWERGONNECTINGTO � � PUBLIC:SEWER SEP7ICTANK,SEEPAGEPITOR � � NEWHOUSESEWER � PITSAND/ORORAINFIELD � ' � HOIJSESElNERCONNECTINGTO CONNECTA!?DITIONAL. ' BUILDING OR WORK � P631VA7E DISPOSALSVSTEM �f_PTIC TANN,aEEP.PIT(SI d+� COIVNEC7 ADbiTIONAL BLDG.OR ANp/OR DRAINFIELD WORK TO HOUSE SEWER ._ OVERFL.OW SEEPAGE P17,DRAINFIELI3 CESSPOOL � �RVWELL❑ � ExTN.,CESSPOOL.DRYWELL,MANHOI_E ALTER,RE'PAIR OF2 ABANpON 1-10USE�� � � qLTER,REPAIR,SEWER OR SEWER OR DISPOSAL SYSTEM SEWAGE DISPpSAL SYSTEM DISCONNECT PLUG AND � ABANDON HOUSE SEWER BACKFfLL SEPTIC T.4NK5(� �WRIER S Permit � � � s��P,arris�O cessPoo�s❑ v AUTHOR9Zd4TIOPJ TOTAL FEE �/ALIDATION I HAVE AT THIS DATE A C�NTRACT WITH YHE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE D6SCRfBED E7CISTfNG DWIELLIN TOTHE PUBLIC SIEW R SfGNED Tt-0IS DAY OF 7 � . =�� '� ��,�'�� � � � ON/P1ER OR OWNERS AGENT !�,,,,,_� �� /� �'� :� .� � 1 Ck ADDRESS� Ml..l i � (, I-HEREBV ACKNOWLEOGE THAT I HAVE READ THIS APPLICATIOfd �`�t `��� � �' c'��.' �•�- � � � AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMP�Y WITH ALL GOUNTV OROINANCES AND STATE LAWS REGULATING � ,,j �J ;? {� ��r�;�; 1 PLUMBING ANO SEWERS. �, 4 � „ A 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTEItED AND/OR LICENSED AS REQUIRED BV Lq5 ANGELES COUNTY AND STATE OF � �,„ .n���f CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE- f SIDE IN,THE ABO DESCRIBED RESIDE f1L PROPER'DO(, SIGNATURE �o _ OF PERMITTEE � W'� I .. . . . . . . . . . . . . I ...zwnanae.:vu�a;nms*wunw�.-o-.n.uv..�a+�aw.,�e,mw.� . �....n.m..�..w. . . �wm�.v4.m. . . .. �.--..a' ������A�TB���T��� ���t�9R����������'��� l. 4l�i�l:ATE ALL �?l!lL�3E4�fGS �1�! �R°JPERT�. � 2. If�ld�l�,�'i y ,��� �i;g�lEivS6�� S�L"J;�G� G�!S�t���L Sl°ST�7�It .ttt�lT°rl TIE €�!S7�'�.l�i rS T� �SC�1L�1�li�S .;., . .� .. t�l�lt3 P��?°ERT'�°�li�3CS. �;,-„'�.. . ��.�� . . _., . A. < , , 3.INGiaAi� Stl�� �F S��'iiC °6��VI�-L3�PTH e'�F �,EEP- - � ., A��Pi�(Sl -Sle��'JF i.ESSf'�r�L(Sl. �;: '.;. �. . .:, .;.. 4. if�Dl�'�TF N�RTN DlR�u�'iQN C?�7 PLJT. � e*� `;�,..�.'�' .;. �:'.�. :: : 5. iIV�l��'e�'��C�TFi�d,�CEE1"S IF�C?hsvcR. , � . . ' , A , .• , ,�;',, n .,. - . ... . ...f,.:..,. .. � ... . , . , . r_� -� d...» �''..s . t � .e. � ' ST,Al.LE�'R/V4° F6EL��4�TE� � ,, , . ., ,� >. , ,, , , . . , �._ ..,� ; , . r ,_:m.._