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"'Cff'&q SF,.nA f6 r.l\uuree Otg <br />sqc-ol laPHONEOWNER <br />MAILING AOORESS \33\5 Tarra.vie0 RD <br />"'"c os+A lN€sA INl\zezc <br />NO.EACH <br />I <br />I <br />5.00 <br />10.00 <br />1 st 1 00' + Conn. <br />Ea. Add'l 100'or Fraction <br />Ea. Add'l Conn. <br />15.00 <br />5.00 <br />5.00 <br />each plumbing fixture/trap <br />Dental Unit or Medical Gases <br />FIXTURES <br />Residential fl lndustrial E Commercial <br />Rivate Sanage Disp. System 30.00 <br />GAS PIPING <br />GAS SERVICE 1 to 4 Outlets I 5.00 qe <br />1.00 <br />5.00 <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />Ou'.r-8dl,.t D.dr.tlon <br />I hereby allirm lhal I am €xsmpl lrom thc Conlraclo/s Licens Law lor lhe lollowing roaon (Ss. <br />703.l.5. Busaness and Protessions Codo. Any cily or county wtrich tequites a permil lo conslruct. <br />altar. improve. d€molish, s repair any struclure, prior to its isuanco. also toquir$ tho Spplicant <br />for sch permat lo lile a sqned stalomenl thal he B licens€d puBuanl lo the provisbns ol lhe <br />Contractor's Licenss Law (Chrpter 9 (@mmencing with Seclion 7@0) ol Oivision 3 ot the <br />Eusiness and Prot6sions @de) or thal he is exempl lhsrelrom 8nd ths basis tor lhe slleg€d <br />oxemption. Any violslion ol S€clion 7031.5 by 8ny sppli€nt ,or I psrmil subicls th8 spplicant to <br />a civil penslty ot nol more lhan tive hundrod (blla's (3500): <br />E Sfrtion 70444 l. a3 owner ot lha property. or my employses with wrCB s lheir sole compen- <br />salion. will do the wort. rnd th€ 3tructure is rcl anlfldsd or ollded lor $le. <br />El s*tlon 7(x4B l, a owns ol the proporty. am sxclusivaly contreting wirh licomod <br />contracloB lo comtrucl th6 project. <br />Oate Owner (Sig.) <br />Contrclo[ lrra Only <br />CONTRACTORlhFr Hnt /.r+L &PPL/.AT/A 4?y-otot <br />PHONE <br />u <br />AOORESS/?Vgt DEvrrTL <br />I"u'533dCITY/r+KE EtSrtuoae <br />I hereby aflrrm lhal I am lrcensed uoder the provisions ol Chapler 9.3olthe <br />Contraclor (Sig.) <br />and <br />Oate <br />ol 1-? <br />Clsss <br />rs rn full <br />I lEEby alfirm that I havc a carlilieto ol @nsl to ssll-insure, <br />subiocl to lhe Worker's Comp€nstion Laws ol <br />]aotlc. To AP9llcrt: <br />ll alter makrng lhrs Ce.trfrcate ol Exemptron. you should become subltrt lo the Worker's Compen- <br />provrsrons o, llE Labor Code. you musl lorlhwilh comply wilh such ptovBions or lh6 <br />Worksr's Com- <br />Applrcsnt (Sig.) <br />OGlJltbn <br />the <br />penstpn <br />Date App[cant (Srg ) <br />Cstali€d copy is lilad wilh th€ <br />Ve.ilied <br />Calilornia <br />rn any manner $ a to <br />rn lha peimil is issued. I shall rct 6mployany <br />permrt shall be demed,evoked <br />06te <br />Expires <br />Alt. or Repair of Drainage - Vent Piping <br />100.00 <br />10.00 <br />liemporary Gas Service <br />Water Service Ea. 100' <br />MISCELLANEOUS <br />Owr2" <br />Water Heater - Electric or Gas <br />Backfloriv Device 2" or Less <br />Water Piping Ea. 100' <br />Owr5 <br />Rain Water Piping (buried) Ea. 100' <br />Vacuum Breakers 1-5 <br />Water Soflner <br />Sprinkler <br />Rain System - for Drain <br />lnd. Waste lnterceptor <br />Pool Traps <br />Deck Drain System - Per Drain <br />or VentRepair/Alt. <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 <br />Violation Fee <br />Plan Check 650/o of zubtolal <br />Pc#Receipt No. <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />DATE <br />(minimum 20.00) <br />Date <br />(s0.00)Erplr.ltoo <br />Thrs permil shrll erpire by limilrtim and bocoma null and vcid il lhe wotk autho.rz€d by lhis <br />lErmit is not commonced wilhin 1&, dsys lrom the date ol this permit or it work sulhorized by lhis <br />pe.mit is sBp€ndod d abandoned ,t any timo Ittor lho work is cmmonctd lor a ,Eriod o, 180 <br />drys. A n* pdmrt ghall bg obtainod fiBl b€loro such worl cen ba mmmned. <br />tcerrity thet I hrve rsd thisapp,,*ffi;ffim, <br />Applicani or Agont <br />I agr* <br />tocomply with all crly ordimncs and stala laws <br />ol lhrs city lo enls <br />PERMIT ISSUEO 8Y (Sig.)ehq (sis )PERMIT No <br />LDING <br />Aut-PD . oN n- O? 17o -/1-4121 <br />6- tt <br />o o <br />APPLICATION AND <br />'ptutrtBtNc PERMTT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />66,7-2738 <br />APPLICANT FILL IN AREA BELOW <br />@g-Izo <br />ooI <br />m <br />ct)a <br />U-loJ <br />avZ-l <br />ta <br />9, <br />F <br />o\ <br />o <br />F <br />$ <br />6 <br />Drslnbulron I Copy 2 File Copy 3 Finance Copy 4 Applrcsnl Copy <br />cs-61 I <br />rorAu " <br />w)v <br />SEWER <br />Surs + t-o,rpgR ASSOC. <br />I 5Qt) <br />I <br />I <br />aulhofi zed reprBenlalionpurpos* ,/ ,/o,r"4dfr <br />t1