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APPLICATION AND .
<br />f TTdECHANICAL PERMIT
<br />(TYPEWRITE OR PRINT IN INK)
<br />o CITY OF SANTA ANA
<br />206 W. 4th Street
<br />667-2738
<br />APPLICANT FILL IN AREA BELOW
<br />q,g-Izo
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<br />-3JOB ADORESS Sa,tb7*-
<br />"'" (o6u \- yl-,r4*
<br />Oiltar{ulbr O.dribn
<br />I hereby altirm thal I am ermpt lrom lha Contracto/s Licffs Lm ld lhs follorying reeson (Scc.
<br />7(8t.5, Businoss and Prcl6sions Coda Any city or county which r€quir6 a p€tmil to construcl.
<br />aller. improva. demolish, or rapaar any struclu16. prior to it3 63uanca, ds r€quiro8 tho applicent
<br />lor such permit to lilo a signod 3trtomenl that ha B licon3€d puEuant lo the provisions o, ths
<br />Conlractor's Licsss Lff (Chspts 9 (@mm€ncing wilh S€c'tion 7m) ol Divbion 3 ol lh€
<br />Busine$ 8nd Prol63ions Cod€) or that he ia sxsmpl lhorotrom 8nd the bab ld the alleg€d
<br />oxmption. Any violrlion ol Seclion 7031.5 by any applicrnt tor 8 permit subiecls the spplicanl to
<br />a civil penalty ol nol more than tivs hundr€d dollrB ($500):
<br />E S""tion 704{A l. as owna ot ths properly. or my omployc with w.9€3 6 lheir sle compen-
<br />sslion, will do the woit. and the structure B not int€nded or oflsod tot sale.
<br />E S*tion 7O4,lB l. ss ownd ol the property, em exclusivoly contracting with licensod
<br />contraclof,3 lo construct the pro,st.
<br />Dale Owrer (S19.)
<br />ContrEto[ tXo Only
<br />""*%-0, T */e-az?-7200
<br />PHONE
<br />CITY STA o
<br />EACH FURNACE INCL. DUCTS AND VENTS
<br />EACH COMPRESSOR, BOILER, OR HEAT PUMP
<br />EACH AIR HANDLING UNIT OR VAV BOX
<br />Outdoor Dual Packaged Healing or Cooling
<br />EACH TOTALD lndustrial ! Commercial NO.
<br />Up to 100,000 BTU
<br />Over 100,000 BTU
<br />EACH ABSORPTION SYSTEM
<br />100,000 BTU to 1 ,000,000 BTU
<br />1,000,001 BTU to 2,@0,000 BTU
<br />Heat Pump Compressor less than 5 HP
<br />5HPto30HP
<br />31 to 50 HP
<br />Orcr 50 HP
<br />Air Handling less than 2,000 CFM
<br />2,000 CFM to 10,000 CFM
<br />Over 10,000 CFM
<br />MISCELLANEOUS
<br />Floor Furnace
<br />Heater; Suspended, Wall or Unit
<br />Com'l Drler Vents
<br />Decorati\€ Fireplace (Wood or Gas)
<br />sys.Bepair, Alt. or Add. to any
<br />Range Hood with Duct and Fan (Type l)
<br />15.00
<br />20.00
<br />25.00
<br />30.00
<br />25.00
<br />40.00
<br />25.00
<br />30.00
<br />10.00
<br />10.00
<br />10.00
<br />25.00
<br />15.00
<br />'15.00
<br />10.00
<br />15.00
<br />15.00
<br />15.00
<br />I hereby elti,m thet I am licssed under th6 provisions ot Chapler 9. Oivision 3
<br />7c-70Code. ild my license E in lull torce and eff*t.YfWnGsand
<br />on" lttl't? contracror
<br />*5fl7/7 ",*"
<br />7o.no
<br />9O-rrc
<br />7rro-o
<br />tUortan Coil?ailrabn D.drtbo
<br />I h6r6by arlirm lhat I hev€ a cerlilicals ot @n3mt to sell-insura. or a csrtitacta ot Woiksr's Cor
<br />I cerraty that rn the perlo.manceol lhe work lor whach this
<br />porson in any mrnner !o I lo b€come 3ubieci lo th. Worte/s Comp€rrgation Liws o,
<br />Calilomis
<br />Nollcc To Apdkit:
<br />ll alts makrng lhrs Cerlrficateol Exemptron, you should becomesubiet lo theWorker's Compen-
<br />salron provrsrons ol the Labor Code. you musl lorthwith comply wrlh such provisrons or this
<br />permrt shall be demed revoked
<br />t2-7t-t7Oale Applicsnl (Sig )
<br />Date Applicant (Sig.)
<br />with the inspection department
<br />I shall not mploy sny
<br />gansatEn lnsu,rance Cdtirred @py B tilod
<br />?:l:,,* l/?a vs,r,ed By (s,e )
<br />Each Vent Fan Connected to a Duct
<br />Hood with Duct and Fan (Type ll)15.00
<br />OI by
<br />(50.00)
<br />Fire Damper lnstallation
<br />Fan Coil lnstallation
<br />Fire Extinguishing System
<br />Each Elaporatiw Cooler
<br />lncidental Gas
<br />15.00
<br />15.00
<br />20.00
<br />10.00
<br />15.00
<br />15.00
<br />Subtotal
<br />Violation Fee
<br />Penalty Fee (when applicable)
<br />Plan Check 650/0 ot subtotal SZ Q (minimum 20.-00)
<br />Receipt No.Pc#Date
<br />6.5nPlan Check (Adjustment)(*t)tb
<br />lssuance Fee 10.00
<br />Erpkdon
<br />This permit shall axpire by limitation and bocoma null and void il th€ woIk authorizod by lhis
<br />p€rmit is not commenced within l@days trom lhe date ol this pormil or i, wort sulhori2ed by this
<br />tE.mit is suspended s abandoned al my tima alts ths wort is cmrenced tor a period ol 180
<br />days. A new permit shSll b€ obtained fiat beloro such work can be rocommscod
<br />Apgllcmt,r O.drdo.r
<br />I cGrtrty that I hee rdd this spplacatim and state that the ebove intormstion is corroct. I er€€ to
<br />comply with ell cily ordinanG and slala laws ralaling to building coarstuclion. end hsr€6y
<br />authoaized ropre6entation ol this city to ents upon the abovemmtioned propsty lor ioFpetim
<br />Applrcant s Agent (Srg ):::;-u4 TOTAL PERMIT FEE
<br />o^rE /2
<br />€(mlnimum $35.00)
<br />PERMIT NO.
<br />flLOqr.",FrEDBY(sie) ylBUILOING
<br />PERMIT No PERMTT TSSUEO BY (Slg )
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<br />LY)
<br />1-412]-rn,4-/a{6,f 2
<br />Orslribution t lnspftlor Copy 2 Frle Copy 3. Finance Copy 4. Applicant Copy
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