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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 <br />WAPPLICANT FILL IN AREA BELOW <br />(DgrIzo <br />oo!m <br />@ <br />@ <br />\ <br />NBL <br />w <br />.y <br />AODRESS <br />.f</L - o/) o <br />PHONE*It-r-/b* 0/r.*d <br />E lndustrial fl Commercial NO,EACH TOTAL <br />5.00 <br />10.00 <br />each plumbing fixture/trap <br />Dental Unit or Medical GasesNG <br />SEWER"''[rfu >]1r-*STATE/ZIP <br />?a tal 15.00 /g- <br />5.00 <br />5.00Ea. Add'l 100' or Fraction <br />Private Sewage Disp. System <br />1 st 1 0O' + Conn. <br />Ea. Add'l Conn. <br />30.00 <br />OI'I,-lu[(,.t D.dalbn <br />I hereby srtirm that I am 6rcmpl lrom the contractor's Lrcens Law lor lhe lollowing ro8on (S€c. <br />7(I3l 5, Businss and Prcl6sions Code Any cily or county which requaros a p€tmrl to construcl, <br />alter. improve. dsmolish. or repair any structure, prior to ils issuanco. alSo roquiros the applicant <br />tor $ch permit to lile s sign€d statem6nt thal he B licensad puBuanl to the provisions ol the <br />Conlraclds Licm$ Lil (Chaptar 9 (comm€ncing with Setion 7@O) ol Oivbaon 3 ot th6 <br />Eusrnoss end Prole3sioB @de) or that he is exompt th€relrom and the baSas tor the allegod <br />exemption AnyviolstaonotS€clion70:rl.Sbyanyepplicantlorapermilsubiectsth€spplicantto <br />6 crvil p€nally ol not mora than rive hundrod (bll8B (35m): <br />E S*tio, zOlu l. as owner ot lhe propeny. or myemployaas wilh wag6a3 thoirsolecompen- <br />s€tion. will do the mrt, end the strcture is nol intefld€d d ot d€d tor sale. <br />E S*tion 70448 L as owner ol tho proporly. am oxclusively conlracting with licslod <br />contraclm to conslrucl lhe proioct. <br />Oate Own6r (Sig.) <br />Conlrxio[ t a. Only <br />V;T:'i,^) ^. 0 0 A b t), ;tA- .t /.'14 - narfl <br />PHONE <br />STATE/ZIP <br />ADDRESS <br />I here(y afrirm thal I am licensed under lha provisions ot <br />PrdEms Code. ild mv tcense rs <br />,Y,?"o*"fl$ogi ",*"IaGEAGT contractor <br />3orthe Businsslnd <br />7an lull lorce and etlfft. <br />(sig.) <br />subiect to tho Wdkor's Compensetion Laws ol <br />l5tlc. To Aepllcil: <br />ll afler makrng thrs Ce.lricate ot Eremplaon. you should become sublst to the Workeas Compen- <br />p.ovisions ol the Lsbor Code. you must lorllilith comply with 6uch provisaons s this <br />shsll bo demed ,evolgd <br />Crpardon <br />This p€rmil shrll axpiro by limilatim and bocomo null and void il lh€ rcrk authorizod by this <br />p€rmit is not commncsd wilhin 100 day3 trcm lhe dsle ol lhis pormil or i, work 8uthotiz€d by thas <br />pormat ls susp€ndod o( abandoned at any tim srtd the woIt is commonced tor s perbd ol 180 <br />A new permil shall be obtained ,i6t belore such work c8n bs Ecommanced. <br />Apefc..ra.. O.d.rdqr <br />I ceAity thst I have 6d lhis applicrtim and slat6 thst lhe ebove <br />Oclrrlbr <br />thal lhe <br />,iledis lhewithcopy <br />Applicanl or Agenl <br />Applicant <br />Date (Sig 1 <br />Expires <br />cerlilacste ol Worter's Com- <br />depanmsnl <br />this parmit is issued. I shell nol 6mployBny <br />I eore to <br />with all city ordrnanm and state laws <br />ot lhis city to amer upon <br />I hereby atlirm lhat I have I ot consenl to <br />pensatron <br />Oale <br />p€M in any mnffi I a lo <br />Csliromia <br />Alt. or Repair of Drainage - Vent Piping <br />10.00 <br />(minimum <br />I <br />GAS PIPING <br />Water Service Ea. 100' <br />GAS SERVICE 1 to 4 Outlets <br />Oyer2" <br />Ea. Add'l Outlet <br />Backflow Device 2" or Less <br />Repair or Replace Gas Piping <br />Owr5 <br />Temporary Gas Service <br />Vacuum Breakers l-5 <br />MISCELLANEOUS <br />Repair/Alt. Drainage or Vent <br />Water Heater - Electric or Gas <br />Water Ea. 100' <br />Rain Wbter Piping (buried) Ea. 100' <br />Water Softner <br />Lawn Sprinkler <br />Rain System - Per Drain <br />lnd. Waste lnterceptor <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 />Penalty Fee (when applicable) <br />Violation Fee <br />Plan Check 650/o of sublotal <br />Pc#Receipt <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />(50.00) <br />Date <br />(minimum 20.00) <br />>r.l* S1 oPEBMIT ISSUED BY (Sig,)tiJii?,yss4bL7u,^n,,K,,\ l,- <br />6J), ,l.r-* p ar), *"rt 141 17D s-/3- rl <br />,pta,rc 4 P't't- <br />VALIDATION (OFFICE USE ONLY) <br />(ACCOUNT <br />'r <br />1-ar2) <br />Orsl.ibulion 1 lnspector Copy 2. Fale Copy 3. Finance Copy 4 Applicenl Copy <br />CS-61 I <br />FIXTURES <br />//5<- <br />/2 <br />1 <br />, <br />/,t <br />tV /. f -/n)-- t) o -Otza.;