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*ppircATroN AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />t a <br />CITY OF SANTA ANA <br />206 W. 4th Slreet <br />667-273a <br />APPLICANT FILL IN AREA BELOW <br />@qrIz <br />ool, <br />ma(!> <br />K,t)l-l <br />lop <br />I <br />Iu7 <br />CJ7 <br />, <br />o') <br />C <br />F.f-\ <br />o\\ <br />I <br />ID <br />IF <br />I <br />lh <br />lb <br />'"gqD'q sANlA fe uirAcc DR *D <br />gryb- ottoOWNER <br />Suts*uotDeY< ASs(-. <br />MAILING AOOR€SS-E5(E* tra.\rrvie*l RD <br />ICITYCos-rA lncsA STATE/ZIPa. qz62c <br />Omd-Bdld.i Oadf, .tlon <br />I hereby alfirm lhat I am exempl trom ltE Conlraclor's Lrcense Law lor lhe lollowrng reason (S* <br />T03l5.BusrnessandP.ol6sroosCode Anycityorcounlywhrchrequiresapermrtloconslrucl, <br />aller. rmprove. demolsh. or repair any structure, pnor to rls rssuance. also requrres the applrcanl <br />lo. such permrl lo file a sEned stalement thal he rs lrcensed pu6uanl to lhe provrstons ol lhe <br />Conl.actor's License Law (Chapler 9 (commencrng with S$lron 7mO) ol Divrsion 3 ot the <br />Busrness and Prot6sions Code) or lhat he rs exempt lherelrom and the basrs lor lhe alleged <br />eremptton Aoy vrolalron ol Sectron 7031 5 by any applrcanl lor a p€rmrl subtets lhe app[cant to <br />a civrl penalty of not more than tive hundred dollars (t5O0) <br />E S*t,on 7044A l. as owner of the propeny. or my employes wrth wag6 as therrsolecompen- <br />salron. wrll do lhe rcrk. and lhe slructure is nol rntended or ollered lor sale <br />E S*t,on 70448 L as owner ol the properly. am exclusrvely cont,actrng wrth lrcensed <br />conlraclors lo construct the proiecl <br />Date Owner (Sig ) <br />Contrrcloo t ra Only <br />"ilPZii aru r cAL ftPPilcnfiu,u 0 '7 <br />/7 <br />"^VigaoEL,/ /uoa.e_"")r?K r' <br />3ol th€ <br />Contractor (Sig.) <br />heraby that I am lrcens€d unda, th6 provisions ol Chapter <br />etlectis rnaod my ,"ttXy <br />subjecl to lhe Wdke/s Comp€nsation Lsws ol <br />Noflc. To AlEllcrl: <br />ll atler making lhrs Cerlrficate of Eremptron, you should become sublsl to lhe Worker's Compen- <br />salron provrsrons of lhe Labor Code. you musl lorthwrth comply with such provErons or thrs <br />permrl shall b€ demed revoked <br />I he.eby altirm ol Wortd's Com- <br />Oclrdlon <br />have <br />Verifred By <br />CalitornB <br />Oate Applicant (Sig.) <br />pensation <br />which lhis permil is issued. I shall not employ any <br />copy is ,iled with the <br />ol@nffitto <br />rn the pedormance ol lhe <br />Applicanl (Sr9.) <br />Oate <br />Erprres <br />lResidential Elndustrial DCommorcial NO.EACH <br />each plumbing fixture/trap 5.00 <br />Dental Unit or Medical Gases 10.00 <br />1st 100'+Conn.15.00 <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 100'or Fraction 5.00 <br />Private Sanage Dsp System 30.00 <br />GAS PIPING <br />GAS SERVICE 1 to 4 Outlets 5.00 <br />Ea. Add'l Outlet 1.00 <br />Repair or Replace Gas Piping 5.00 <br />Temporary Gas Service 100.00 <br />M]SCELLANEOUS <br />Water Heater - Electric or Gas 5.00 <br />Water Ea. 100'10.00 <br />Rain Water Piping (buried) Ea. 100'8.00 <br />Water Sottner 4.00 <br />Alt. or Repair of Drainage - Vent Piping 10.00 <br />Laivn Sprinkler -t 6.00 <br />Rain System - Per Drain 10.00 <br />lnd. Waste lnterceptor 8.00 <br />Pod Traps 5.00 <br />Deck Drain - Fer Drain 3.00 <br />Repair/Alt. Drainage or Venl 10.00 <br />Vacuum Breakers 1-5 I 5.00 <br />Orcr5 1.00 <br />Backfloriv Device 2" or Less I 5.00 I <br />Over 2"10.00 <br />\A/hter Service Ea. 100'10.00 <br />Subtotal <br />Fee (when applicable) <br />Violation Fee (s0.00) <br />Plan Check 650/o of subtotal (minimum 20.0O) <br />Receipt No.Pc#Date <br />Plan Check (Adjustment) <br />lssuance Fee 10.00 <br />TOTAL PERMIT FEE (minimum <br />PERMIT <br />ErCr.os <br />This permit shall expare by limitation end btrome null and void al the work sulho.iz6d by this <br />pormit i3 not commncod wilhin 180 day3lrcm th€ dal6 ot thir pormit o. ilrcrt aulhdazod by this <br />permil i3 Suspend€d o. abendonod at any lim allot thg work i3 commncsd tor a lpriod o, 180 <br />days. A ner psmf shsll be obtained liBl berore Such work can ba rcommenc€d. <br />ADacrfl H.rdqr <br />I certity that I hsve read thi! spplicltion 6nd ilAe that lho rbo|o I agrs <br />locomply with all crty ordinanc6 and stete law6 <br />ol this cily to <br />Applacanl or Agent (Sig. <br />authonzed reprBentat,on <br />gUrgOSA ,/ ,/o,n*AZ {a(PERMIT ISSU€O 8Y (Sig.)lyki,i?,sthl <br />Ntt* lees PD oN l^- o?,7O s-t?'r1 1-412) <br />Orstrrbutron. t lnsp6lo. Copy 2 File Copy 3 Frnence Copy 4 Applicsnl Copy <br />cs-6r r <br />romC <br />FIXTURES <br />\l ,4\a <br />SEWER <br />\'1.<g <br />I /Dz