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t a <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-2738 h" <br />APPLICANT FILL IN AREA BELOW <br />(DgrI2o <br />ool, <br />mb <br />U' <br />NBL <br />Kesidential Dlndustrial ECommercial NO.EACH TOTALJO8 ADORESS*z"iVa- )-",A 7u U^lL-,-UaZo <br />SYL -o//a <br />PHONE*%h*r-0*.o FIXTURES <br />Dental Unit or Medical Gases <br />each plumbing firlure/trap 5.00 <br />10.00ILING <br />L7htu--b <br />SEWER <br />1st 100'+Conn.1 15.00 /5- <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 10O' or Frac{ion 5.00 <br />Private Sewage Disp. System 30.00 <br />Orn ?€ullrar Oadtalbo <br />I hereby sllirm thst I am exempt lrom the Cslraclor's Licens€ Llw lor the tollowinO r6a3on (Soc. <br />7(Xr'l 5. Business tnd Prot6sions Code. Any cily or county which requir6s a p€rmit lo consttuct. <br />aller, improvs. demolBh. or 16pair any struclur6. prior to its rssuance. al3o r€quires the applicsnl <br />,or $ch permil lo ,ile 8 sqnod statment that he as liens€d po6uanl to th€ provi3ions o, the <br />Conlnctor's Licen$ Llw (Chaptgr 9 (commencing wilh Soction 7m0) ol Divilion 3 ot the <br />Business and Prot6sioG Co{re) or th8l he is exempl thorarrom and the basis lor the allsg€(, <br />eramplion. Any violelion o, S€c,tion 7031.5 by any spplidnt lor I p€rmrt 3ubjects the applicsnl lo <br />a civil ponally ot not mor6 than liv€ hundrod dollars (Ssm): <br />E S*tion zOgl l. 8s ounor ol lh€ propsny. ormyomploygoswrth wago8 as lheirsolecompon- <br />gltion, will do tho rcrt. and lh€ strrctura is not intof,ded or ollered tor $la. <br />E S*tion 7O4aB I. s omd o, the propody. 6m exclusively cmtreting with licemed <br />contractoB to con3trucl lhe pioiect. <br />Oate Owner (Srg.) <br />ConlrrioB tjt. Only <br />WTi'ff ,-,,,), I fi lA / rr-fi---b74- o7o7 <br />PHONE <br />l8 <br />STATE/ZIPCITY <br />I hereby allirm that I em lrcensed und€r ths provi3ions ol Chapts <br />Prol6srons Code. and my licen$ rs in lull lorce and <br />oa" S! 5 8J- contractor (sis.) <br />3ol the Busan6s and <br />7Lrcense No fu*Ofr","" <br />subioc,t to the Worker's Comp€n$tion Lsws ol <br />Nodc. To Aeglbrl: <br />ll atter makrng lhrs Cerlricale ol Exemplron, you should become sublat to lhe Worker's Compen- <br />salron provrsrons ol lhe Labor Code. you must lorthwrlh comply wrlh such provrsrons or thrs <br />permrl shall be demed revoked <br />(sig.) <br />OGlr.tbn <br />thepensaloncow <br />Date <br />VeriliedExprres <br />I hereby allirm lhal I havs e ol consent lo a certificato ol Worttrs Com- <br />insp€ction departmenl. <br />whichlhis pormit is issusd, I shall nol omployany <br />Dete <br />- <br />(Sig 1 <br />orr^s-tS -8? Appricanr <br />I cartily thal in the p€rtormenceoltho <br />pe73m in any mnn€r !o as to <br />Celilomia <br />Alt. or Repair of Drainage - Vent Piping <br />'t0.00 <br />I <br />Water Service Ea. 100' <br />Over 2" <br />Backflow Device 2" or Less <br />Over 5 <br />Vacuum Breakers 1-5 <br />Repair/Alt. Drainage or Vent <br />PIPING <br />GAS SERVICE 1 to 4 Outlets <br />Ea. Add'l Outlet <br />GasRepair or <br />Temporary Gas Service <br />MISCELLANEOUS <br />Water Heater - Electric or Gas <br />Water Ea. 100' <br />Rain Whter Piping (burid) Ea. 100' <br />Water Softner <br />Bain System - Per Drain <br />lnd. Waste <br />Pool Traps <br />- Per DrainDeck Drain <br />5.00 <br />100.00 <br />1.00 <br />5.00 <br />5.00 <br />10.00 <br />10.00 <br />10.00 <br />8.00 <br />5.00 <br />4.00 <br />1.00 <br />10.00 <br />5.00 <br />6.00 <br />10.00 <br />10.00 <br />3.00 <br />8.00 <br />5.00 <br />Subtotal <br />Fenalty Fee (when applicable) <br />Violation fue <br />Plan Check 650/. of subtotal <br />Pc#Receipl llo. <br />Plan Check (Adiustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />DATE <br />(50.00) <br />Date <br />(minimum <br />PERMIT <br />.9O (minimum 20.00) <br />ErDh.lton <br />This p€rmit shall arpiro by limilstion and b€como null and void rl the mrk ruthtrizod by thir <br />p€rmit is nol commcncad within 100 d8ys |rom the dats ol lhis pormil d if rcrkrulhorizod by lhi! <br />pormit i3 susponded or sbendoned al any tim efis ths worl is cmmncsd lor a Friod o, 180 <br />days. A new psmit sh8ll be obteinod liBl b€lor6 $ch work can be rocommnc€d. <br />I catfity th.l I havo rsd lhB app,,*rffi;ffi* <br />o,,".G1.582 Applicenl or Agent <br />I e€rs to <br />andcomply wrth all crty ordimncB and suite law! <br />authotirod reprosanlalion ol lhis city lo enld <br />purpos€3 <br />hb?i*ilifr .S<t/-o{"r^,,,.K.,o-PERMTT ISSUEO 8Y (Sig ) <br />o-e-!-W @ et- 7?7a!-ffifvALroATroN (oFFrcE usE oNLY) <br />(ACCOUNT r11-41?) <br />/ Ptt't <br />v <br />Oistribution I lnspfftor Copy 2. Fle Cogy 3 Fanance Copy 4 Applicant Copy <br />cs-61 r <br />N <br />?41- <br />/ <br />Lawn Sprinkler <br />/ <br />I <br />/ <br />a- <br /><_ <br />t- <br />?n- <br />lo