HomeMy WebLinkAboutNo Permit Number76A642D
CE 808 (REV. 6/78)1/79 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES BUILDINO AND SAFETY
FOR APPLICANT {O FILL IN DISTRICT NO GROUP MAP PROCESSED BY
BK PG
BUILDING
ADDRESS
ph LOCALITY CONNECTION DATA
NEAREST -
4 CROSS ST. STATION DEPTH `
I
MANHOLE REFERENCE '' `' '4UPR
sp LOWEROWER
MAIL TYPE OF CONNECTIONT,LENGTH FROM
ADDRESS Y. CURB `P. L. - M.L. TO P.L.
it CITY TEL. NO
R.C. NO ,tCO. IMP. NO, JOB NO
LEGAL
DESCRIP 1TON LOT NO. TRUNKPERMITERMIT NO. ROADA PERMITN O
BLOCK TRACT
1.
AFFIDAVIT
I WAIVER EASEMENT RECORD. INSTR. NO. DATE
ja SIZE OF LOT NO. OF BLDGS.
NOW ON LOT HWY. OR ST. WIDENINGUSEOF
BUILDINGS STATE ENCROACHM EIVT
PERMIT NO.
CONTRACTOR INDUSTRIAL
j' WASTE APPROVAL
tl ADDRESStr GHARGESI':'.
CITY .:.. '.'...; '. TEL. NO. ,. s ; `._ CONNECTION CHARGE FEE
STATE LIC. LICENSE NO. _ '. 1. ,'-
CLASS '-' REIMBURSEMENT FEE _ - O
NO. DESCRIPTION OF WORK FEE cAPPROVALS E
HOUSE SEWER CONNECTING TO DATE INSPECTOR'S SIGNATURE
PUBLIC SEWER
II
SEPTIC TANK, SEEPAGE PIT OR NEW HOUSE SEWER
PITS AMD/OR DRAINFIELD
HOUSE SEWER CONNECTING TO CONNECT ADDITIONAL
S PRIVATE DISPOSAL SYSTEM BUILDING OR WORK
CONNECT ADDITIONAL BLDG. Pi SEPTIC TANK. SEEP, PiT(5)
WORK TO HOUSE SEWER AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN., CESSPOOL, DRYWELL, MANHOLE CESSPOOL DRYWELL
ALTER. REPAIR OR ABANDON HOUSE w
SEWER OR DISPOSAL SYSTEM ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT -MUG AND
ABANDON HOUSE SEWER
8ACKFILL SEPTIC TANKS
OWNER'S Permit seep. Ptrls) cEssPooLS
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE- HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING' DWELLINGTOTHEPUBLICSEWER.P CsA
SIGNEDTHIS DAY OF is __
OOWNEROR
WNERS AGENT
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE'READ THIS APPLICATIONANDSTATETHATTHEABOVEISCORRECTANDAGREETOCOMPLYWITHALLCOUNTYORDINANCES f-, t
AND STATE LAWS REGULATINGPLUMBINGANDSEWERS.
IHEREBY CERTIFY THAT IAM PROPERLY REGISTERED AND/ORLICENSEDASREQUIREDBYLOSANCOUNTYANDSTATEOFCALIFORNIATHATORIAMTHELEGALOWNEROF, AND INTEND TO RE- SIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE F
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