Laserfiche WebLink
a oAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273t) <br />/l+r'^' <br />APPLICANT FILL IN AREA BELOW <br />@grIz <br />ool,mo <br />(N <br />{s <br />S. <br />r, <br />N <br />37oL k ,#, Y o lJr'^l lr-o - *EJOB AODNESS <br />Ho-,,ih',r.r- b-u*-t 516-o//oPHONE <br />TOTAL <br />FIXTURES <br />Dental Unit or Medical Gases 10.00 <br />STATE/ZIP <br />G <br />ZL <br />MA <br />CITY SEWER <br />1 st 1 00' + Conn.1 '15.00 /i- <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 100' or Fraclion s.00 <br />Ow-800.r.r O.d-ttbo <br />I heraby altirm lhat I am ermpl lrom tt? Contraclor's Licens€ Law tor lh€ lollowing reaon (S€c <br />7031 5, Busrn8s and Prol6saons Codo. Any city or counly whach roquirs a permil lo construct. <br />rllar, rmprovo. demolish, oi ropair lny slruclure. p.ior to rls rsuanca. also requirs the lppliflnt <br />,or such permit to ,ila a sign€d 3tatemst thal he is licensed puBuant lo the proyisions o, the <br />Contractor's Lrcm$ Law (Chapter 9 (commncing with Section 7@0) o, Oivision 3 o, the <br />Eusinsss and Prot6sions Code) oi thst he is exsmpl tharetrom 8nd the basis lor the sllogod <br />er6mpton. Any violalion ot Soction 703t.5 by 8ny applicant tor e permit subioctr lhe applicent lo <br />8 civil psnally of not moro than livo hundred dollaB (35@)r <br />E SaclaonTO44A l.asownorollheprop€rly.ormysmploy6gswilhwag€sastheirsolecompon- <br />Eltaon. wrll do the wort, and th€ structure B nol intsd€d or ottgrod tor s8le. <br />E S*,,on 70448 l. as ownd ot lh€ prop€rty. am orclusivsly co{rtreling with licens€d <br />contracloG lo construct lhe proi*l <br />Oete <br />- <br />Owmr (Sig.) <br />Conlracio[ t,tr Only <br />WTh,;-t alili,t;,lo7l-nto7 <br />PHONE <br />CITY STATE/ZIP <br />I hereby Sftirm thal I am licsn$d under lhe provisions ol Chapter_ <br />Prolessrons Code. and mv hcense rs <br />,{,(R.f:fr,a93 ",,",i,,"r;y'*f contracror <br />in lull force and etlect <br />(sig ) <br />subiect to the worker's Comp€nstion Laws ol <br />Lotca To Appllcrl: <br />lf atle. makrng thrs Cerlrtrcale ot Exemplron. you should become sublst lo the Worker's Compen- <br />salron prgvrsrons ol the Labor Code. you musl fonhwrlh comply wrlh such provrsioos or lhrs <br />permrl shall be demed revoked <br />ol Wo,t6r's <br />Dete <br />Exprres <br />I the <br />Ven liod <br />Calrlo.nra <br />Dlle <br />- <br />Appliclnt (Sig.) <br />OElrlbnWoitm <br />of consent to <br />rs tilsd with the Citypen$tron Insuaance <br />which this ps.mit rs issu6d, I shall not employ any <br />any manner 30 a5 to <br />Applicent <br />I hereby aflirm that I have a <br />Erpardo.r <br />This p€rmit shall expire by limilataon and b€come null and void i, tho rcrk authdizsd by this <br />FErmit ia mt comrcnc€d wathin 180 doys tom lhe date o, lhis permit tr il rcrk ruthorizod by thi3 <br />p€rmil is suspend€d or abrndoned rt rny tam slls th6 woa is commncod lor a potiod ol 180 <br />day3 A nB pdmit shall bG obtained tiBl b€rqe sch worl can bo ,€@mmenc8d. <br />897€€ lO <br />to8nd state@mply with all <br />this city to enter <br />Applrcsnl o. Agent <br />Appllc.il.t Otdf,atlo <br />I cortity lhol I heve rsd lhis applicatim and thal the ebove <br />authorizsd <br />purpos6 <br />Alt. or Repair ol Drainage - Vent Piping <br />10.00 <br />30.00 <br />Subtotal <br />DATE <br />(minimum 20.00) <br />Private Sanage Disp. System <br />Whter SeMce Ea. l0O' <br />PIPING <br />GAS SERVICE 1 to 4 Outlets <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />Temporary Gas Service <br />M]SCELLANEOUS <br />Water Healer - Eleclric or Gas <br />Water Piping Ea. 100' <br />Rain Water Piping (burk#) Ea. 10O' <br />Water Softner <br />-tLawn Sprinkler <br />Rain System - Per Drain <br />lnd. Waste lnterceptor <br />Fool Traps <br />Deck Drain System - Per Drain <br />Repair/Att. Drainage or Vent <br />Vacuum Breakers 1-5 <br />Over 5 <br />Backflow Device 2" or Less <br />Over 2" <br />5.00 <br />100.00 <br />1.00 <br />s.00 <br />5.00 <br />10.00 <br />10.00 <br />10.00 <br />8.00 <br />s.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 />Fee (when applicable) <br />Violation Fee <br />Plan Check 65% ol subtotal <br />Pc#Receipt l,lo. <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />(50.00) <br />Date <br />(minimum <br />PERMIT <br />l -U ,g? ,/tA-oPERMIT ISSUED BY (S'9.)I{*ayisrLr? u, *K <br />O 0 -Lol o * ^ .,', -l- ,9y, llrl 'l q 7D y't,0, hL S./t t9 <br />/vALroATroN (oFFrcE USE ONLY) <br />(ACCOUNT rl 1-4r2) <br />Drslnbutron 1 lnsp6ctor 2 File Copy 3. Finance Copy 4 Applicant Copy <br />cs-6r 1 <br />?_L <br />! lndustrial ! Commercial NO.EACH <br />each 5.00