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o t <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />ffi7-27*f{{- <br />APPLICANT FILL IN AREA BELOW <br />(Dc-Izo <br />oo], <br />ma <br />cn <br />\\ <br />\ <br />I <br />NO.EACH TOTAL@esidentialD lndustrial E CommercialJOB4 <br />"V;-,U*"r-- 6nn*r, . <br />lFxorue5'//"' o //o <br />ualLrr.rc 416oness33t5 3.rr,^;-*,"''bnL 7rz--a--STATE/ZIPTaazC <br />Ounr-Bulld.t D.dt tbn <br />I hereby arrrrm that I am erempt l,om the Contractor's Lrcense Law lor the lollowrng re6oo (S& <br />7031 5. Busrness and Prol6srons Code Any city or county whrch requrres a FErmtt lo conslruct. <br />aller, rmprove, demolish. or reparr any sl.ucture. pnor to rls rssuance. also requtres lh€ applicant <br />lor such peimrl lo lile a sgned statement thal he rs lrcensed pu.suant lo the provtsons ol lhe <br />Contraclor's Lrcense Law (Chapler 9 (commencrng wrth Sectron 7@0) ol Oivasron 3 ol lhe <br />Busrness and Prol6srons Code) or thal he rs exempt tt€refrom and the basts lor lhe alleged <br />exemplron Any vrolalron ol Sectron 703 1 5 by any applrcanl tor a permil subrects the apptucant lo <br />a crvrl penally ol nol mo.e than ive hundred dollars (S5OO) <br />E S*l,on 7044A l. as owner ol lhe properly. or my employes wrth wages as lheir sol€ compen- <br />salron wrll do the rcrk and the structure is nol rnlended or ollered lor sale <br />E S*t,on 70448 l, as owner ot the p.operly, am exclusrvely contracthg wrth lrcensod <br />contractors lo construct the proiet <br />Oale Owner (Srg ) <br />Contlrbn lr.. Only <br />b7L1- D7D7 <br />PHONE <br />"'" Xry',, f-hr),-, -STATE/ZIPq237 D <br />I heraby afi.m lhal I am lrcensad under lhe provisions of <br />Cods. md my lien* is in lull torce and <br />Contractor <br />Pro16srons <br />flfrp.. <br />'.otc. <br />To APPllc-l: <br />ll alter makrng thrs Certrftcale ol Exemptron, you should become sub,trt to lhe Worke/s Compen- <br />salron provrsrons ol the Labor Code. you must lorlhwrth comply w(h such p,ovrsrons or lhts <br />permrl shall be demed revoked <br />of consenl lo <br />Dclmllon <br />of <br />California <br />this parmil is issuad, I shtll notemployany <br />to the Worker's Comp€nsalDn Lils ot <br />whrch <br />subjmt <br />copy is lil€d wiih the City <br />Dete <br />- <br />Applic8nt (Sag.) <br />pensatron lnsu,ance <br />I hereby atirm that I have <br />FIXTURES <br />each plumbing ftxture/trap 5.00 <br />Dental Unit or Medical Gases 10.00 <br />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 30.00 <br />GAS 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 />Gas Service 100.00 <br />MISCELLANEOUS <br />Water Heater - Electric or Gas 5.00 <br />Water Piping Ea. 100'10.00 <br />Rain Water Piping Ea.100'8.00 <br />Water Softner 4.00 <br />Alt. or of - Vent 10.00 <br />Lawn Sprinkler 6.00 <br />Rain - Fer Drain 10.00 <br />lnd. Waste lnterceptor 8.00 <br />Pool Traps 5.00 <br />Deck Drain System - Fer Drain 3.00 <br />Repair/Alt.or Vent 10.00 <br />Vacuum Breakers 1-5 5.00 <br />Orcr 5 1.00 <br />Backtlow Device 2" or Less 5.00 <br />@er 2"10.00 <br />Water Service Ea. 100'10.00 <br />Subtotal <br />Penalty Fee (when applicable) <br />Violation Fee (50.00) <br />Plan Check 650/o of subtotal ,6.5O (minimum 20.00) <br />Receipt M.7C Pc#Date <br />Plan Check (Adjustment) <br />lssuance Fee 10.00 <br />TOTAL PERMIT FEE <br />DATE -)7- <br />ErDarr0on <br />ThB permit shall oxpire by limitltim and beome null 8nd void il the mrk authorizod by this <br />permilisnotcomm€ncodwithin l8Odly3 lromlhodalsotthiEpermitorilwortsuthori26dbythis <br />parmil is 3uspended or abandonsd at 6ny lim6 Itld ths worl is commsncad tor a poriod ol 180 <br />days. A nfr psmit shall be oblsined ,iBl b€rda sch wort can bo rscommn@d. <br />AFfcarll H.rdqr <br />I corlity that I havc rdd this applicalim 6nd sllte that th€ !b@s <br />Applic8nl or Agent <br />corrocl. I 80r€o_ <br />andcomply wth all city and state l8m releting lo <br />thi3 city toauthorized <br />purpos6 <br />PERMTT TSSUEO BY (Sig.)n0-Bgltii$. 5rU2 j u, ,,i,",n, <br />-2r-- ^----!, hvt /t4-2?7o y'Wm. S.t*$ <br />vALroATroN (oFFrcE usE oNLY) <br />(ACCOUNT r11-4r2) <br />/? -l-8- <br />, <br />Oistnbutron lnspeclor 2 Ftle Copy 3 Frnance Copy 4 Applicanl Copy <br />cs-61 1 <br />q <br />Oate <br />Erprres Verified <br />Applrcant <br />lhe