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a oAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OB PBINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273a h,," <br />APPLICANT FILL IN AREA BELOW <br />(D <br />E-Izo <br />ooI <br />moa <br />t <br />*U";\i. <br />"!--t" .Y' - U'tl,-, - 4 F <br />- O/to <br />33 <br />STATE/ZIP <br />2-,G <br />PHONE <br />NG <br />CITY Tao,"-; <br />q 5.00 ,9 <br />10.00 <br />NO.EACH TOTALE lndustrial E Commerdd <br />each plumbing fixture/trap <br />Dental Unit or Medical Gases <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />SEWER <br />1st 100'+Conn. <br />Ea. Add'l Conn. <br />Ea. Add'l 100'or Fraction <br />Private Sewage Disp. System <br />PIPING <br />GAS SERVICE 1 to 4 Outlets 5.00 <br />Ea. Add'l Outlet 1.00 <br />Bepair or Replace Gas Piping 5.00 <br />Ornar-tu0rrar Dadraf bn <br />I hereby ertirm that I am exempt ,rom tlp Contraclor's Lrcens Law lor lhe rollowing roagon (Sec. <br />7@.l.5, Busrnes and Prol6srons Code. Any city or county which requr16 a pormit to conslruct. <br />alter. improve, demolish. or repaar any slructure. pflor lo its isuance. ds reguiroslhe applicant <br />lor such p€rmil lo tile a signsd stelemsnl lhal he is licensed pursuanl to lhe pIovisiom ot lho <br />Conlractor's License Law (Cheptor 9 (commsncing wilh Seclion 7@O) ol Oivision 3 ot the <br />Busines and Prol6siss Codo) or thal he is sxampt thorstrom and lhe baci8 lor tha allegod <br />exemplion Any violetion ol Secton 7O3l 5 by any applicant lor 8 pormil sbiets lhe spplic8nl lo <br />a civil p€nalty ol nol mofe lhen live hundr€d dollaB (S@) <br />E S*tion zOae l, as ownerol tho property. or myemployeswilhwsgG s lhersolocomp€n- <br />salion. wrll do the mrk, 8nd th6 structuE is not antonded or olldod loi sale. <br />E S*tion 70448 l. as owffi o, lhe properly. am €xclusavely contracting with licenrod <br />contracioG to construct lho proitrl <br />Oate Owrer (Srg ) <br />100.00 <br />5.00 <br />Conlrmlon lraa Only <br />10.00 <br />ffffilTL",2 a"uuir,-;L7*-o7a7 <br />PHONE <br />8.00 <br />Water Heater - Electric or Gas <br />Rain Whter Piping (buried) Ea. 100' <br />Gas Service <br />Water Soltner <br />Vvater Piping Ea. 100' <br />4.00 <br />Alt. or Repair ol Drainage - Vent Piping 10.00STATE/ZIP <br />?63eo Larvn Sprinkler 6.00 <br />10.00Rain System - Per Drain <br />lnd. Waste lnterceptor <br />Jod Traps 5.00 <br />I horaby allirm that I am licens€d under the proyasions ol Chapts 3 ol the <br />No <br />Code. and my licen3o rs in lull force and ettel <br />Deck Drain System - Per Drain 3.00 <br />Repair/Alt. Drainage or Vent 10.00 <br />5.00 s <br />1.00 <br />Vacuum Breakers 1-5 <br />Over 5 <br />5.00 5 <br />10.00 <br />10.00 <br />subiecl to the Workar's Compensation Laws ol <br />l5$c. To APellcil: <br />ll atter makrng lhrs Ceflricale ol Exemptron. you should become subr*t lo the Worker's Compen- <br />salron provrsrons ol lhe Labor Code. you must torthwrlh comply wrlh such provrsrons or this <br />permrl shall be demed revoked <br />ComFrulbn O*lJtlbn <br />of Workar's <br />Oate <br />ths of <br />(srg ) <br />VeralEd By <br />any manner so s to <br />Applicsnl (Sig.) <br />ot consenl to <br />the City <br />this permit is issusd. I shall notomployany <br />pensatron lnsu.ance. Certiti€d copy <br />I h€reby alfirm thal I have <br />Oate <br />Exprres <br />Date <br />(minimum 20.00) <br />Backflow Device 2" or Less <br />Water Service Ea. 1@' <br />Over 2" <br />Subtotal <br />Penalty Fee (when applicable) <br />Violation Fee <br />Plan Check 650/o of subtotal <br />Receipt Pc# $ <br />Chec* (Adjustment) <br />(50.00) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />ErDkdo.l <br />This pormil shall srpira by limilation 6nd become null and void i, the wo* euthorir€d by this <br />pormit is not commenced wilhin 180 dsys trom the dals o, thi3 permit or il work authorizsd by thig <br />p€rmit is suslmded or abandonod al any lime rlttr th€ worl is commonc€d tor I poriod ol ,|E0 <br />days. A nil lsmil 3hall be oblranod tiBlab€torc 3uch wort can bo <br />AtDlicanl or Agent <br />I corlity lhal I hsve reed thrs and slete that tha above I agre to <br />and state laws relating to6oply with all <br />of lhis city to sntersuthorized <br />pu.pos6. <br />DATE 5'/ <br />10.00 <br />LOING <br />No (sig.))b >23- s7PERMIT ISSUEO 8Y (Sig.) <br />1-4121 <br />Orslnbul I lnspector Copy 2 File 3 Finance Copy 4 copy <br />cs-61 1 <br />FIXTURES <br />8.00 <br />(minimum $3!,00) -4)- <br />l^l/* o,u- <br />Contrector (Sig