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t o IAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W 4th Street <br />667-2738 <br />t <br />APPLICANT FILL IN AREA BELOW <br />g,grIzo <br />oo,ma(t <br />! <br />K,',IJ <br />lolr <br />I <br />I <br />("47Z <br />-.iv <br />+)-\ <br />Cr(- <br />oc\ <br />on <br />s <br />\ <br />a <br />! <br />X Residential nlndustrial !Commercial NO.EACH TOTAL,3ff6h <br />SntorA re . utuurce DR'*,+FIXTURESOWNER <br />SUto4lpture-R Asstr-5Lt6- Ol toPHONE <br />each plumbing fixture/trap G 5.00 -3o o'9 <br />Dental Unit or Medical Gases 10.00.B3t5 SarRurcO RD <br />MAILING AOORESS <br />SEWER"Eo-=*o ln Esq.ff','4\ezb <br />Om.r-&fld.r Nralbn <br />I hereby atrirm lhal I sm axempl ,rom the Cmtracto/s Lrcms Law lor lhe following reason (Scc <br />7031 5. Busine$ 8nd Prol63rons Cods Any city or county which requaros a pormit lo construct. <br />aller. improve. demolish, oi repgir any struclure, prior to its bsuance, also roquir6s the applicsnt <br />lor such parmit to lile a 3igned statement thSt he is licens€d puBuant to lhe prcvisions ol the <br />Contractor's Lacens€ Lew (Chrpler I (commendng with S6tion 7m) ol Oivision 3 ol the <br />Busino3s rnd Pror6raonr Cod€) or thlt he is oxompl lhorelrom and ths basis lor the sllsgod <br />cxmptlon Any vaolelron ot Saction 7031.5 by any applicrnt lor I permit subisls the applicsnt to <br />I civil penelly ot not mors lhan tive hundred dollars (35IF) <br />E S*tlon UO4A l. as ownerol the propsrly, or myemploy@swalh wag€6 as lh€irsolecompon- <br />Salion. wrll do lhe rcrt. snd the strElure is nol inttrded or ottered lor sole. <br />E S*r,on 70448 l. s owffi ol lh3 pop€rty. am erclusuely contracling aith licffs€d <br />conlracloG lo cOnstruct lhe proJtrt <br />Oate <br />- <br />Owmr (Sig.) <br />ContrE{o[ t,3a orrty <br />AOORESS/r 7R / D,Extgt-Alt. or Repair of Drainage - Vent Piping <br />a9 <br />lst 100'+Conn. <br />Ea. Add'l Conn. <br />Water Softner <br />Ea. Add'l 100' or Fraction <br />Rain Water Piping (buried) Ea. 100' <br />ftilate Sewage Disp. System <br />PIPING <br />GAS SERVICE 1 to 4 Outlets <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />Temporary Gas Service <br />MISCELLANEOUS <br />Water Heater - Electric or Gas <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />5.00 <br />100.00 <br />1.00 <br />5.00 <br />5.00 <br />10.00 <br />10.00 <br />4.00 <br />8.00 <br />"v'ff330CITY.l.epg Etstuoa€ <br />I hereby Sllirm th8t I am [censd under lhe provisions of Chsptq 3ol the Businss "fl. <br />Conlractor <br />and my licen* is in and ellel <br />subiecl lo lhe Worker's Comp€nslion Laws ol <br />taotc. To Apeflcrt: <br />It alttr making lhrs C€rtitrcsleolExemplim. you should bscomasubiecl tolhoWorke/sComp6n- <br />salion prilrsims ol the Lsbor Code. you must lorlhwith comply wath such provBions or lhis <br />permit shell be demad r*ok6d <br />Erpartlqr <br />This pormil shall erpira by limitetion and bocom null 8nd void il lh€ rcrt lulhorizod by thl3 <br />permit is not @mmencod within lSOdsys rrom lhe dsta ol thrs pormit or irwork suthoriz€d by thiE <br />parmit i3 96p€ndod or absndoned at any tim ertei lha work is commnc€d tor ! p€riod ol 180 <br />days. A n* pdmit shall be obtainad liBt b€rda sch worl can be recommonced. <br />Atlearf'' N.rrfar <br />I certity lhat I haye r8d lhis epplietion and JA6 that tho .bo6 <br />which thrs permrt is rssued, I shail not employ any <br />I aore€ to <br />OGlJalbn <br />a <br />I the ol lhe <br />Calilornra <br />Applacent o. Aganl <br />ol Wortd's Com- <br />dopartmonl.copy rs liled with the <br />Verilied ByExpires <br />Applicant (Sig.) <br />lowrrh all city ordimncG and slete laws <br />ol lhis city lo onior <br />I tErcby atfirm lhat I have a ol @nset lo <br />Oate <br />- <br />Applicanl (Sig.) <br />pensetaon <br />Date <br />10.00 <br />\ <br />I <br />q <br />6.00 <br />10.00 <br />10.00 <br />10.00 <br />8.00 <br />5.00 <br />5.00 <br />'r.00 <br />3.00 <br />5.00 <br />10.00 <br />Laltrn Sprinkler <br />Water Service Ea. 100 <br />Rain System - Fer Drain <br />Over 2" <br />Backflow Detticr- 2" or Less <br />Owr5 <br />Vacuum Breakers 1-5 <br />Repair/Att. Drainage or Vent <br />lnd. Waste <br />Pool Traps <br />- fur DrainDeck Drain <br />Subtotal <br />DATE <br />Fenalty Fee (when applicable) <br />TOTAL PERMIT FEE <br />Violation Fee <br />lssuance Fee <br />Plan Check 65% of subtotal <br />Receipt No <br />Plan Check <br />(50.00) <br />(minimum 20.00) <br />Date 2 <br />(minimum <br />PERMIT <br />'l ec* <br />e@8NG <br />No PERMIT ISSUED BY (Sig.) <br />Aru Cffi PO oAr m-O?qlo ^rtrn //r,C <br />VALIDATION (OFFICE USE ONLY) <br />(ACCOUNT <br />'1 <br />r-412) <br />Drslnbulion I lnspector Copy 2 File Copy 3 Frnance Copy 4 Applrcent Copy <br />CS-61 I <br />t <br />1q4 <br />5e <br />Water Piping Ea. 100' <br />in any manmr s a lo