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o IAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273a /h,,- <br />APPLICANT FILL IN AREA BELOW <br />g,q-Izo <br />oo,maa <br />(Qesidential D lndustrial E Commercial NO.EACH <br />X ;5'E )^f--?r- I t ; r/.*- u &L o <br />sll'at t o <br />PHONE <br />-t\, <br />MAILING <br />"'ufu V^r4ar STATE/ZIPq 2b>b 15.00 <br />Ea. Add'l Conn. <br />t2 5.00 <br />10.00 <br />TOTAL <br />FIXTURES <br />each plumbing fixtue/trap <br />Dental Unit or Medical Gases <br />SEWER <br />1st 100'+Conn. <br />Ea. Add'l t00' or Fraction 5.00 <br />Private Sewage Disp. System 30.00 <br />GAS PIPING <br />Ortl. -tulld.r O.drnbn <br />I hereby Itlirm that I am ox€mpl lrom the Cslraclo/s Licas Law tor the tollowing rsaon (Soc. <br />TGil 5. Busines and Prot8srons Code Any c(y or counly which requirs e p€rmrl to construcl, <br />alter, improre. demolrsh. or rgparr any structure. prior lo ils issuonce, also reguiros the applicanl <br />,or such permit to tile I sign€d slatemsnt that he is licqnsod puBuanl lo tha prcvisioru ol lhc <br />Conlracior's Lacense Law (Chapler 9 (commncing with Soction 7m) o, Oivision 3 o, th€ <br />Susiness and Prore3siom Cod6) or thot he is oxmpl tharalrom and the bsis lor the allog€d <br />exemplaon. Any vaolalion ot Soclion 7031 5 by Eny rpplienl tor I permit sbi*ls the applicant lo <br />a ciul penally ol nol moro thln tive hundred (bllaB (3500): <br />E S."tionZO{A l.!sownerolthepropony,ormyampblEssrthwsgessth€irsolacompen- <br />38tion. will do the rcrk. and lhe structuro is rcl rntond€d d ollsod ,oi sal6. <br />E S""tion 70448 l. a! ownor ol lho propeny. am exclusryely cmtreting wilh lcans€d <br />contracloE to comlruct lhe projecf <br />Oate Owrer (Srg ) <br />Contrrton t,!. Only <br />CONTRACTOR <br />1|io--4o* -- l- aztztaZ,;tzlt-O707 <br />PHONE <br />AooRESs / f/ 7 7rt D"-,8 <br />STATE/ZIP <br />&-qr)3o <br />I hereby atlirm lhel I am lacens€d under Ihe provBiom o, Chapts g <br />subiecl to the Worker's Comp€n$tion Lews ol <br />l{olbr fo Agdlcnl: <br />ll alter makrng thrs Certrtrcate ol Eremptron. you shoutd b€come subirt to the Worke/s Compen- <br />provrsrons ol the Labor Code. you must tonhwrlh comply wtth such provtsions or lhls <br />shall be dftmed revoked <br />ErCra0on <br />This pormit shall sxpirs by limitstim and b€como null and void il th€ worl luthorizod by this <br />pormit i3 not commencod within 180 days lrom tha dsle ol this permit Or il rcrk aulhtrized by this <br />pormit is 3uspondod or lban(bnod rl any lime artd lha mrl is cmmncod lor a ,Eriod o, 'l8O <br />A nar psmil shsll be obtorned ,i6l b€rore such w6k can b€ @mmencod. <br />eggfcad'. D.d.ntqr <br />I cerlity thal I have roed thB apolicrlim rnd slrls thal lhs rbovo <br />3ol the Busin6s andal <br />Contracto. (Si9.) <br />ot Worker's <br />Applicant (Sig.) <br />7 <br />insp€ction <br />Verfred <br />Oete <br />Expires <br />lhe <br />Applrcant or Agenl (Sig <br />Code, and my hcense is rn lull fo.c6 and etl*t. <br />Cslilornrs <br />DGlrdlon <br />ol @nsst lo sll-insure, <br />copy is lilsd uth the City <br />I lprcby afti.m lhat I have a <br />pensatron lnsurance. <br />whrch this permit is issued, I shall nol omploy 8ny <br />I agrs <br />andto8nc slete lawscomply wilh all <br />o, this city to <br />Ods <br />- <br />(sig.) <br />olth€ <br />autho.ized <br />purpos6 <br />anymannersBto /o- <br />10.00 <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 Piping <br />Backflow Device 2" or Less <br />Temporary Gas Service <br />Over 5 <br />MISCELLANEOUS <br />Vacuum Breakers 1-5 <br />Water Heater - Electric or Gas <br />Repair/Alt. Drainage or Vent <br />Water Piping Ea. 100 <br />Deck Drain System - Fer Drain <br />Pool Traps <br />lnd. Waste lnterceplor <br />Rain System - Per Drain <br />Lawn Sprinkler <br />Rain Water (buried) Ea. 100' <br />Water Soltner <br />Alt. or Repair of Drainage - Vent <br />5.00 <br />100.00 <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 />Penalty Fee (when applicable) <br />lssuance Fee <br />Violation Fee <br />Plan Check (Adjustment) <br />Plan Check 65% of subtotal <br />Pc#Receipt No. <br />(50.00) <br />Date <br />(minimum 20.00) <br />BUILDING <br />PERMIT No (si9.l ?1"9- da o-PERMIT ISSUEO BY (Siig.) <br />ed /4 74 7O4,,6-19.9? <br />(ACCOUNT r1 1-412)a-(L <br />Drstributron 1 lnsp*to, Copy 2 Fna Copy 3 Frnance Copy 4 Applicanl Copy <br />cs-6r l <br />a <br />5.00 <br />t