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o o <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W 4th Street <br />667-2738 <br />APPLICANT FILL IN AREA BELOW <br />(!grIzo <br />ooI <br />m <br />@a <br />IGll <br />lo <br />I <br />L.D <br />cn <br />Z <br />-t <br />'+1n <br />C <br />?'r <br />aa <br />() <br />n <br />lf <br />!h <br />1C5'q shN'iA f€ ui.,ace on. # r <br />PHONE <br />54tb-d/0 <br />OWNER <br />Sur.tftoqre€ ASSoc- <br />Residential Ulndustrial DCommercial NO.EACH <br />Dental Unit or Medical Gases <br />5.00 <br />10.00 <br />each plumbing fixture/trap <br />FIXTURES <br />&i \5 {ArRuteu)RD <br />MAILING AODBESS <br />CITYCos-tl freSg trl'42ac <br />Ourr-edld r D.dr.lloo <br />I haraby sllirm lhal I am exemgt lrom th6 Contracto/s Lrcens Law tor the lollowing rBaSon (Sec. <br />7001 5. Busina$ and Prol6sions Cods. Any city or county which requir6 6 permit to construcl. <br />alter. rmprove. dmd,sh. or rapsar any structurs. prior lo rls r$uance, ds requiros the applicant <br />lor such permil lo ,ale a sign€d ltatement thsl he rs licensad puBuant to th6 provasions ot the <br />Conlractor's License Lil (Chapl€r 9 (commncing with Soction 7@0) ol Oivisaon 3 ol the <br />Busine3s 8nd Protossiofls Code) or that he is oxempl lhorsrrom 6nd tho b836 ,ot thc sllegod <br />axemptaon Any violation ot Seclion 7!31 5 by any applicant tor a pormit 3ubiects tha 8pplicrnl lo <br />a civil p€n8lty of not more than live hundr€d dollaB (t5O0): <br />El S""tion zOla l. es owner ol the property. ormyomploy€Bwilhwag6 6 theirslscomp€n- <br />ralion. will do the rcrt. and tho struclure is nol intend€d or ollgred lor s8le. <br />f] S*tion 7(X4B l. as ownd ol tha prop€rty. am €xclusivaly cmtreling with licensed <br />conlracloG lo conslrucl ths proirct. <br />Dale <br />- <br />Owner (Srg ) <br />Conhrclo[ lrtr Only <br />/cA f"Vtl-otot <br />ADORESS <br />DOLO <br />Oivrsion 3of the <br />subjocl lo lhe Worker's Comp€nstion Laws o, <br />ltofca To ArPllcrl: <br />ll alter makrng lhrs Certricaie ol Exemplroo, you should become subjcl to lhe Worker's Compen- <br />satron provrsrons ol the Labor Code. you must lonhw[h comply wrth such provasions or thrs <br />permrt shall be demed revoked <br />ol Worker's <br />Cily <br />?ou,*r, <br />rfofnra <br />Oate Applicant (Si9.) <br />OGlrdlon <br />I heraby <br />Pensatron <br />permil is issued. I shallmt employany <br />copy is liled <br />ol consenl to <br />anymenner$slo <br />in tha pertormsnco ol the <br />Applrcanl (Sig.) <br />Oate <br />Erprr6s <br />SEWER <br />1st 100'+Conn.15.00 oO <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l l0O' or Fraction 5.00 <br />Private Sewage Disp. System 30.00 <br />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 />Water Heater - Electric or Gas 5.00 <br />Water Piping Ea. '100'10.00 <br />Rain Water (buried) Ea. 100'8.00 <br />Water Softner 4.00 <br />Alt. or Repair ol Drainage - Vent Piping 10.00 <br />Lawn Sprinkler {i 6.00 <br />System - Per Drain 10.00 <br />lnd. Whste lnterceptor 8.00 <br />Pool Traps 5.00 <br />Dec* Drain System - Per Drain 3.00 <br />Repair/Alt. Drainage or Venl 10.00 <br />Vacuum Breakers 1-5 I 5.00 (P <br />Over 5 1.00 <br />Backflow Device 2" or Less 5.00 <br />Over 2"10.00 <br />Water Service Ea. 100'10.00 a) <br />Subtotal <br />Penalty Fee (when applicable) <br />Violation Fee (s0.00) <br />Plan Check 65% ol subtotal (minimum 20.00) <br />Receipt t{o.16'l Pc#Date <br />Plan Chec'k (Adjustment) <br />lssuance Fee 10.00 <br />Erpanuo.r <br />ThB parmit shall erpire by limitalion end bocome null and void it th€ work authdiz€d by this <br />parmil B not comm€ncod within t8o dsys rrcm the dat6 ot thb permil o( il wort 8uthorized by lhis <br />p€rmil B surp€ndgd or abandonod at any limo afltr lh€ work is cmmncod ,or a potiod ol 160 <br />days. A n* pdmit shsll be obtainad liBt b€rde 3uch wort can ba |@mmncad. <br />r carrry rhar r have rsld rh.s appri*,mltffi*" <br />comply with 6ll cily ordimncB and stat€ lswg rolsting lo <br />I agrm <br />Oate Applicaot d Agenl <br />ol this city loSuthori:ed <br />purposes <br />VERI <br />BUILOING <br />PERMIT No PERMIT ISSUEO BY (Sig. <br />At- c-r\- o?gp. 0Ar,0 <br />(ACCOUNT 1-41 2) <br />Oislribution: l. lnspstor Copy 2. Fils Copy 3. Finance Copy 4 Applicsnt CoPy <br />cs-61 r <br />rortrt <br />C t/ss <br />I <br />MISCELLANEOUS <br />I * <br />/ <br />I <br />TOTAL PERMIT FEE (mlnimum $115.00)rc] | 511 I <br />Code. and my lrense rs in <br />No '1laoQ3 <br />Conlractor <br />ot <br />lorce and