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o t <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-2738 <br />APPLICANT FILL IN AREA BELOW <br />c,g-Izo <br />ool, <br />ma <br />@ <br />0Jo <br />-E <br />d7 <br />Z <br />--) <br />lfifhtr <br />V <br />R <br />o <br />tr <br />s <br />0 <br />fiResidential D lndustrial !Commercial NO.EACH TOTALJOB AODRESS31Oq SAN-\A fE uirl-nce DK.'ttC-FIXTURESOWNERSuutrrotPeq A<soc-4t//- -o/ tD <br />PHONE <br />each plumbing lixture/trap rl 5.00 55* <br />.33r-= €a <br />MAILING AODRESS <br />t tAt.l\G.u)KD. <br />CITYCotrta tf\e-,sa <br />srAfE/ztP <br />G, Qil2O <br />Dental Unit or Medical Gases 10.00 <br />\5 <br />C5L5.00 <br />1st 1@'+Conn. <br />GAS SERVICE 1 to 4 Outlets <br />Ea. Add'l Conn. <br />GAS PIPING <br />Ea. Add'l 100' or Fraction <br />Private Sewage Disp. System <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />Ea. Add'l Outlet 1.00 <br />Omr-Au[d., Oodf,rlbn <br />I hereby afirm lhat I am exempt trom ltE Contractor's Lrcense Law lor lhe lollowrng reason (Se <br />T03l5.BusrnessandProlessronsCode Anycityorcouotywhrchrequiresapermittoconslruct. <br />aller. rmprove. demolsh. or reparr any structure, pror to rts r$uance. also requrres the applrcanl <br />lor such permrt lo ile a srgned stalement thal he rs |censed pursuant to lhe provisions ol the <br />Contraclor's Lrcense Law (Chapter 9 (commencrng wilh Setron 7m0) of Drvrsion 3 ol lhe <br />Busrness and Prol6srons Code) or lhsl he rs exempt lherelrom and lhe basrs lor the allogod <br />exempl,on AnyvrolationolSectionT03t.5byanyapplrcanllorapermrtsubj*tstheapplicantlo <br />a crvrl p€nalty ol nol more lhan ive hundred dollars (35@) <br />El Sctron ZO44A I. as owner ol lhe properly. o, myemploy€s wrth wags as therrsolecompen- <br />satron, wrll do the rcrk. and lhe structure rs not rnlended o. ollered lor sale <br />E S*l,on 70448 l. as owner ol lhe propedy. am erclusrvely contractrng wrth lrcensOd <br />contracto6 to constrUcl lhe prolsi <br />Oate Owner (Srg ) <br />Conlrrlo[ t,3. Orly <br />CONTRACTOFI"ngcrtru /cftL APPLT c*not ;*2?{-o?bt <br />^'Tff7gt Devrao <br />"t"rl'.e/E ,G/St tuo/?.e "o'v'bs3d <br />I hereby atrirm thal I am licensed under the provisions ol Chapter 9.3ol the Busl <br />Conlractor (Sig.) <br />ldce Bnd gtlectCode, md license is rn <br />Noltc. To APgllcil: <br />ll atler makrng lhrs Ce.lricate of Exemptton. you should become sublcl to the Worke. s Compen- <br />salron provrsrons ol lhe Labor Code. you must lorthwrlh comply wrth such provrsions or thrs <br />permrl shall be demed revoked <br />ol Wo,ttr's Com- <br />I <br />I tEreby altrrm thal I h8ve a <br />subjact <br />Calrlomra <br />Applicanl (Sig.) <br />the portdmanceolth€ <br />an any mannor $ s to <br />C€rtitied copy is tiled with <br />Expires Verified By <br />D8te (srg ) <br />this permat rs issusd. I shsllrcl employany <br />to lhe Worker's Compensation Laws o, <br />pensataon I <br />Date <br />Erpa[lbn <br />Thrs pormit shall erpiro by limitation rnd beome null snd void il tho wk authoriz€d by this <br />pormil i3 nol commncad within lSOdays rrom the dtle ol this pormit q i, work aulhoriz€d by thig <br />permil a3 su3panded or abandonsd at any timo alld lhs work is cmmncod tor a fEriod ol 180 <br />days. A nil prmit shsll be obleined larsl b€rore such wort c6n be rlcommonc8d. <br />rcen.,y that I have read thisapp,,"",m1'lt"H,*.* <br />pur9os <br />all city ordinencE and stale laws <br />ol thrs cily to ont€r <br />Applrcant o. A96nt <br />I sgrs to <br />Alt. or Repair ot Drainage - Vent Piping <br />\o* <br />10.00 <br />PERMIT <br />5.00 <br />100.00 <br />Repair or Beplace Gas Piping <br />Temporary Gas Service <br />Water Heater - Electnc or Gas <br />Water Service Ea. 100' <br />Water Piping Ea. 1@' <br />Over 2" <br />Rain Water Piping (buried) Ea. 100' <br />Backflow Device 2" or Less <br />Water Softner <br />Over 5 <br />Vacuum Breakers 1-5 <br />Sprinkler <br />Rain System - Per Drain <br />lnd. Waste lnterceptor <br />Pool Traps <br />Deck Drain System - Per Drain <br />/Alt. Drainage or Vent <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 subtotal <br />Pc#Receipt l.lo. <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />DATE <br />(50.00) <br />(minimum 20.00) <br />Date <br />rLor -o-PENMIT ISSUEO BY <br />Att- fces (1) olo ln- oQl2o st&1-4121 <br />Orslnbulron t lnspmtor Copy 2. Ftle Cogy 3 Frnance Copy 4 Applicenl Copy <br />cs-61 r <br />ar <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />I <br />I <br />I <br />MISCELLANEOUS <br />5c- <br />! <br />i <br />I <br />lE@- <br />-g <br />looE <br />,0 <br />Dclmllon <br />to sll-rn3uro.