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o IAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />, <br />APPLICANT FILL IN AREA BELOW <br />206 W. 4th Streel <br />667-27fi <br />tw <br />@g-Izo <br />oo! <br />m(, <br />@ <br />ut <br />t <br />\ <br />*YYU'b J,i- -V,- U; /l--,-a* <br />AGCITYP <br />O /^5.00 <br />10.00 <br />NO.EACH TOTAL <br />5.00 <br />E lndustrial D Commercial <br />each plumbing lixture/trap <br />Dental Unit or Medical Gases <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />SEWER <br />GAS SERVICE 1 to 4 Outlets <br />1st 100'+Conn. <br />Ea. Add'l Conn. <br />Ea. Add'l 100' or Fraction <br />Private Disp. System <br />PIPING <br />Ea. Add'l Outlet 1.00 <br />Repair or Replace Gas Piping 5.00 <br />Temporary Gas Service 100.00 <br />MISCELLANEOUS <br />Ounr-Bulld.r O.drllbn <br />I hereby alfirm that I am erempl from tlE Contractor's Lrceose Law lor the lollowrng reason (Ss <br />7(Xll5.BusrnessandProf6sronsCode Anycrlyo.countywhrchrequrresafPrmrltoconstrucl. <br />alter.rmprove.demolrsh orreparranystructure.pflo.lortsrssuance,atsorequrrestheapplacant <br />lor such permrl lo tile I slgnd stalement thal he rs fucensed pursuanl lo the provigions of lhe <br />Conlractor's Lrcense Lil (Chapter 9 (commencrng wrlh Setron 7@0) of Oivrson 3 of lhe <br />Busrness and Prolssrms Code) or thal he rs exempt theref.om and the basrs for lhe alleged <br />eremplron Any vrolatron ot Seclion 7031 5 by any applicant tor a p€rmil sublsts the applrcanl to <br />a crvrl penalty ol nol more than ive hundred dollars (5500) <br />E S*t,on 7044A l. as owner ol lhe propeny. or my emproyes wrth wag6 as therr sole compen- <br />satron. wrll do the rcrt.8nd lhe slructure rs nol intended or ollered lor sale <br />E S*,ion 70448 l. as owner o, lhe properly. am exclusryely contraclrng wrth lrcenged <br />contracto6 to construcl lhe proi6t <br />Oale Owner (Si9.) <br />Water Heater - Electric or Gas /5.00 <br />@olirbo t r. Only <br />10.00 <br />W^ii"d r,",, r. -o . fl ^i a I -.D,)Lz*-oza z <br />PHONE <br />8.00 <br />4.00 <br />Rain Water Piping (buried) Ea. 10O' <br />Alt. or Repair of Drainage - Vent Piping <br />Water Piping Ea. 100' <br />Water Softner <br />10.00STATE/ZIP <br />O Lawn Sprinkler 6.00 <br />Rain System - Fer Drain 10.00 <br />lnd. Waste lnterceptor 8.00 <br />Fool Traps 5.00 <br />I hereby aflirm lhel I am lrcensgd under the provrsions ol Chapter 9.lhe Busrn6sand <br />7eCode, and my tcen* rs rn lull lorce and et ect. <br />Contrector (Sig ) <br />Class <br />Deck Drain System - Per Drain 3.00 <br />Repair/Alt. Drainage or Vent 10.00 <br />Vacuum Breakers 1-5 5.00 <br />Over 5 1.00(Sig I <br />Backffow Device 2" or Less /5.00 <br />10.00 <br />10 00 <br />subloc,t to the Worker's Compon$tion Laws ot <br />ilodc. To ADPllcal: <br />It atte( makrng thrs Ce.tricate ol Exemptron. you should be@me sublftt lo the Wo.ler's Compen- <br />salron provrsrons ol the Labor Code, you musl todhwith comply with such provisions or thrs <br />permrl shall be demed.evoked <br />Comp.utbn Oclrlbn <br />Wo.kd's Com- <br />Oate Applicant (Si9. ) <br />ol consent to slt-rnsure. <br />Csirtiad copy is lil6d with rho <br />this permit is issu6d. I shall notemployany <br />Applrcanl <br />in theporrormanceol <br />rn any mannor s <br />Calito,nra <br />Oate <br />Expires <br />I horeby at rrm that I <br />pensaton Insurance. <br />(minimum 20.0O)7 <br />Pc# <br />(50.00) <br />Owr 2" <br />Water Service Ea. 100' <br />Subtotal <br />Plan Check (Adjustment) <br />Penalty Fee (when applicable) <br />Violation Fee <br />Plan Check 65% ol sublotal <br />Receipt <br />Erdta0o.r <br />Thrs pemrt shall 6xpim by limitalion end b€come null and void il th€ wort ruthorizod by lhis <br />permil is nol @mmncod walhin 180 days rrcm lh€ delo o, this permit ff il work suthsizod by this <br />p€rmit is su3pmded or abandon€d st 8ny lime rllor lhe worl i3 cornmncad ,or o porbd ot 180 <br />dty3. A nil psmit ahrll bo oblsinod liEt boldo sch wort en bo rcommamed. <br />I cedity thrt I hsve road thB eppti-,m;ffi,n* <br />Applicanl o. Agent (Sig.) <br />to <br />comply wilh all and state laws ralating to building <br />authofized ol lhrs cily lo lssuance Fee <br />TOTAL PERMIT FEE <br />10.00 <br />(srg ) <br />'O-PERMIT ISSUEO BY (Sig ) <br />sla,f-lt't-4121 <br />Oislnbulron 1 Co 2. Filo Cogy 3. Fanance Copy 4 App[canl Copy <br />cs-6r 1 <br />r,.. <br />3 <br />/ <br />) <br /><-J <br />- <br />7g=- <br />bQ)/ oate <br />No