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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 />ffi7-273a /fu- <br />APPLICANT FILL IN AREA BELOW <br />@c- <br />9zo <br />ooI, <br />m <br />U)a <br />q <br />1 <br />tI <br />JOB ADORESS <br />U <br />PHONE2Ab*each fixture/trap <br />NO, <br />b <br />EACH <br />5.00 <br />Dental Unit or Medical Gases 10.00MATLtNG A+RESS <br />33 t'3-PL <br />STATE/ZIPq2 blc"''[sfuYt'rrr*1st 100'+Conn./15.00 <br />Ea. Add'l Conn.5.00 <br />TOTAL <br />FIXTURES <br />5- <br />Ea. Add'l 100' or Fraction 5.00 <br />Private Sewage Disp. System 30.00 <br />GAS PIPING <br />ormr-Sulldor Drdrdbn <br />I llereby elfirm that I em exempt |rom tl€ Contractor's Lrcense Law lor lhe lollowing reason (Sec <br />16l 5, Eusrness and Prol6saons Code. Any city or county which requrres a permit lo conslruct. <br />-r.. rmprove. demolish. or ,eparr any slructure, prior to rts issuanca. als requires lhe 8pp|cant <br />lgr trh permrt lo ftle 8 s€ned statement thal he 6 lrcensed puBusnl to the prcvrsrons ot lha <br />Gtiltr,lor's Lrcen* L& (Chapler 9 (commencing with Selron TCID) ol Orvision 3 ol lhe <br />],r-Er and P.ol6sims Code) or that he is exempt lherelrom and the ba36 lor lhe alleg€d <br />ararpl0r Aoy violston ol S€ctron 7031 5 by any applic.nt lor a permrl sub,ecB the spplicant to <br />a civil p3rally ol nol mor6 than frve hundred dollaG (3500): <br />E Seilo.r fOffe L es owna, ol the propeny, ormyemployffi wrth wa96 as the[ 3olgcomp€n- <br />lliorr. wll ab na Sr*, 8nd lhe struclure is not rntsdd o. orlorod lo. sale <br />E S-lot loaa l. - owne, ol lhe properly. em exclusively cmlrscting with licensad <br />conlr*-to't to oo{r*tal llc proioct. <br />Dare .-- Orner (Srg ) <br />Conlrelon tJr. Only <br />l?9-ozol <br />PHONE <br />30CITY <br />I hereby altrrm lhal I am lrcensed un(br tho proy[irnt ol Chapler 9.3ol th€ BwiBs and <br />7y <br />(sis.) <br />subject lo the Worke/s Compon$lion Lils ol <br />No$c. To AtDlbil: <br />ll aller makrng thrs Cenricate ol Eremptron, you should become subl6t lo lhe Worker's Compen- <br />provrsrons ol th€ Lebor Cocle, yo musl lorlhwith comply wrth 3!ch prdi3ions o. lhs <br />shsll bo dened Boked. <br />Erdr.don <br />Thrs permrl shall exgrre by limilatrm and become null and void it lhe mrk author[sd by this <br />is not commncad within 180 deys lrcm lhe date ol lhis p€rmat q rl work eulho,izod by this <br />is susg€nded o. abandongd at any time atla the work i3 cmmnc€d lor 8 ,priod ol l8O <br />A ntr p€.mit shall be obleanod tiBt b€tore such work on bo ro@mmgncod. <br />Atlc.nl..Hrdon <br />cortify thal I have rerd lhB applicetion and slale that tho aboe I rgrs to <br />of <br />Erprres <br />Oale <br />and <br />V€ri li€d <br />Applrcsnl (Si9.) <br />I hereby atfrrm lhal I have <br />this p€rmit is issued, I shall notsmployany <br />DGlrttbn <br />copy is lilcd wilh the Cily <br />ot @nsst to <br />in any mannor I s <br />lhe porrormsnce <br />Applicant <br />wrlh 8ll and slato la$ relating to <br />city to snts <br />purpos6 <br />Oale Applicanl or Agenl <br />Pensatron <br />Oale <br />( <br />/ <br />I <br />5- <br />(minimum 20.00) <br />GAS SERVICE 1 to 4 Outlets <br />Water Service Ea. 100' <br />Ea. Add'l Outlet <br />Over 2" <br />Repair or Replace Gas Pipirq <br />Backllow Device 2" or Less <br />Temporary Gas Service <br />Over 5 <br />MISCELLANEOUS <br />Vacuum Breakers 1-5 <br />Water Healer - Electric or Gas <br />Repair/Alt. Drainage or Vent <br />Water Piping Ea. 100' <br />Deck Drain System - Per Drain <br />Rain Water Piping (buried) Ea. 100' <br />Pool Traps <br />Water Softner <br />lnd. Waste lnterceptor <br />Rain System - fur Drain <br />Alt. or Repair of - Vent Piping <br />5.00 <br />1.00 <br />5.00 <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 />TOTAL PERMIT FEE <br />Penatty Fee (when applicable) <br />lssuance Fee <br />Vidation Fee <br />Plan Check (Adjustment) <br />Plan Check 65% of subtotal <br />Pc#Receipt tlo. <br />(50.00) <br />Date <br />Lawn Sprinkler $ <br />N-*'/t!*#,if".tflob <br />,ERTFTED BY (sie ).A-d-O'PERMIT ISSUEO BY (Sig,) <br />LQ *, /4 7?7)dJ^(ACCOUNT 1-1121 <br />? <br />Dist,rbution: I lnspector Copy 2. File Copy 3. Finance Copy 4 Appl copv <br />cs-6r r <br />Ssesidential ! lndustrial fl Comm€rcial <br />Ao- <br />ob <br />,q4, -o// a <br />/ <br />-7- <br />100.00 <br />/ <br />/ <br />(minimum $35.00) <br />10007*- <br />Lrcen* No <br />oqand my lrcen* E n lul ,orca lnd afiad\