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e 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,grIzo <br />ool, <br />m(ha <br />*'4'f'6"/" Jr-,f.- Vu Urlln uo b'Y^ l,lr, ,- - on*ry%- o//a <br />NO.EACH TOTAL <br />FIXTURES <br />Dental Unit or Medical Gases <br />each plumbing fixture/trap s.00 <br />10.00 <br />ING A <br />Cl STA 2L SEWER <br />1st 100'+Conn./15.00 /{ <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 100' or Fraction 5.00 <br />Private Sewage Disp. System <br />GAS SEBVICE 1 lo 4 Outlets <br />30.00 <br />s.00 <br />1.00 <br />5.00 <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />OIrr.r-ed(l.r D.dr.l5n <br />I hereby atlirm that I am exempt trom lhe Conlracto,/s Lrcens Law tor lho tollowing reasm (Se <br />TCBl 5. Eusine3s and Prolossaons Code Any city or county whach roquirga a pormal lo conslrucl. <br />allor. amprov€, d€molish. or reEEir any slrucluB. pflo, lo als isuanco. alro raquires lh€ applient <br />lor such psmit to tila a signod statam€nl lh8l he is licgm€d punguant to lhs prDvisioG ot lhe <br />Contretor's Lcens Lil (Cheptar 9 (commncing wilh Soction 7@0) ol OavBim 3 ot lhe <br />Bwiness and Prol6sams Codo) or that hG b sxampt lherotrom and lhe batB td the alloged <br />€romption. Any vDlslloo ol S€clon 7(Xil 5 by any rpplicsnl tor s p€rmil sbicts tha spplicanl lo <br />a civil penalty o, nol mtro then live hundrad dollaB (35mrl <br />E S*fion ZOaa l. as owner ol the prop€dy. or my omplo!€es wrlh w!C63I thoir sole comp€n- <br />sation. will do lh€ mrl. and th€ strrcturo ia mt rnlend€d o, ofltrgd lor sle <br />E S*rion 704/aB l. ss owmr o, the prope.ly. .m srclusivGly conlreling walh liceolod <br />contiaclm to con{rucl lhe proi6ct. <br />Dale Owrer (S'g ) <br />Water Heater - Electric or Gas <br />100.00 <br />5.00 <br />Contirl,or t ra Only <br />Water Piping Ea. 100'10.00CONTRACTOR <br />7h- A "-,, " .-!, /l-AA),, rt)bzlozozPHONE <br />Rain Water Piping (buried) Ea. 100'8.00 <br />Water Softner 4.00I <br />AODRESS <br />Alt. or Repair ol Drainage - Vent Piping 10.00STATE/ZIP?Aazo Lawn Sprinkler 6.00 <br />Rain System - Per Drain 10.00 <br />lnd. Waste lnterceptor 8.00 <br />5.00 <br />I heraby alli,m lhal I am lrcensed under the provisions ol Chaptor 3ol the <br />Proressrons <br />Vlfr€"" <br />Code, 8nd my licanso rs in full torco and etlocl. <br />3.00 <br />10.00 <br />Deck Drain System - Per Drain <br />Repair/Alt. Drainage or Vent <br />Vacuum Breakers 1-5 <br />-Pool Traps <br />5.00 <br />Over 5 1.00 <br />Backflovv Device 2" or Less 5.00 <br />Over 2"10.00 <br />Water Service Ea. 100'10.00 <br />pensalion Insurance Certried copy is ,iled with the City <br />,:olb. To ApPllcrl: <br />It atter makrng lhrs Cerlrfrcale ol Exemplron. you should become subrst to the Work€r's Compen- <br />satron provrsrons ol lhe Labor Code. you musl lorlhwrth comply wrlh such provisrons or lhrs <br />permrt shall be demed revoked <br />Oclmllon <br />this pormit is issuod, I shall not 6mployany <br />to the Workor's Comp€nsation Laws ol <br />which <br />sub,mt <br />Applicant (Sig.)Oate <br />anymannerssto <br />i n I he perrormanca ol ths <br />Applrcant <br />Calilornra <br />Oste <br />Expires <br />I hersby sttirm lhat I <br />Subtotal <br />Fee (when applicable) <br />Violation Fee <br />Plan Check 65% of subtotal <br />Pc#Receipt No. <br />Check (Adjustment) <br />(s0.00) <br />Date <br />(minimum 20.00) <br />ErCrdc.r <br />This p€rmit shsll oxpire by limilslion rnd b.como null and void i, the wt luthorizod by lhia <br />pcrmit B not @mmonc6d wilhin 1&)deys lrom lh€ (tato or lha! pormit or ilworkaulho{ized by tht3 <br />is susp€nded or abandonod al any time atld th6 wort rs cmmncad lor a porod ol 18O <br />A n* pdmat thall b€ oblainad tiBt b€lore such wort crn bo o@mmoncod <br />ADelcrf.t hrdar <br />I cerlily thal I hsve rsd lhis rpglicrlaon lnd Jl.lo lhal Ute aboro lo <br />Applicant or Agont <br />with 8ll and slate rclsling to <br />th6this city to <br />PERMIT <br />(minimum <br />lssuance Fee <br />TOTAL PERi'IT FEE <br />5-t 7- <br />o- <br />10.00 <br />PIPING <br />5:- <br />.5 <br />MISCELLANEOUS <br />Gas Service <br />?yl*,yfi,SruG (sig )tu O-PERMIT ISSUEO BY (Sig.) <br />"U" ealq tU7?7Od-tL <br />(ACCOUNT r-4r2) <br />lt <br />\ <br />o Copy 2 Fle Cogy 3. Frnsnce Copy 4 Applicent Copy <br />cs-61'l <br />Edesidential !lndustrial !Commercial <br />//-r5 <br />/{ <br />-l- <br />1], €-1o-r-,-*,n--, <br />vr-b szJ acc <br />I <br />stkSqy'ts ilrt-,