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o IAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-27fi <br />APPLICANT FILL IN AREA BELOW fu- <br />u,g <br />Iozo <br />oof,m <br />U') <br />U' <br />UJ <br />*\ <br />s <br />oo <br />I <br />sr <br />;fresi<tential Elndustrial ECommercial NO.EACH'f ;';'E L-*,1, l),v/,,r-ra, , s(- <br />offi-fuu-,rur' f^; .5/L-O/tt-s <br />PHONE q 5.00 <br />10.00 <br />15.00 <br />CITY <br />33 <br />STATE/ZIP <br />ab 2-G <br />ING ,2/-5 <br />1st 100'+Conn. <br />JEIYEN <br />Ea. Add'l Conn.5.00 <br />rOTAL <br />FIXTURES <br />Dental Unit or Medical Gases <br />each plumbing fixture/trap <br />Ea. Add'l 100'or Fraclion 5.00 <br />ftivate Sanage Disp. System 30.00 <br />GAS PIPING <br />GAS SERVICE 1 to 4 Outlets 5.00 5- <br />Our.r-lulld.r O.d-nbn <br />I hereby allirm that I em erompl from lh6 Contraclo/s Licsso Law lor the lollowing rcason (Soc. <br />7031 5. Busrn6s and Prol€ssions Coda Any cily or county which r6quiroa a p€rmil to construcl, <br />aller, improve. demolBh. or repa,r any glructuro. prior lo its i$uanca, als r6quir$ lho applicant <br />tor 3uch parmat lo lile a 3rgn€d stalemenl thal he B lrcens€d putsuanl lo lhe prcvisiom ol lh€ <br />Contractor'3 Liconso Lffi (Chrptsr I (commncing wilh S€ction 7m) ol OivBon 3 ol lh€ <br />BusrnBss rnd Proleasims @del or that he is arempt thorolrom 8nd the besis lor tho ellegod <br />orcmplion. Any violrlion ot Saclion 7031.5 by 8ny spplicenl loi I permat sbi*E the applicant to <br />a civrl penalty ot mt mors then irvs hundrsd dollaB (t500): <br />E Saation ZOlll l. as of,n€r ot lhe prop€ny. or myomployeeSwilh wlg€sas lhoarsolacompen- <br />sation. will do the rort. Snd lhe 3lruclure is nol rnlendod or olterod lor sale. <br />E S*tion 70448 l, as owns o, the p,ope.ly. am orclusivoly cmtreting wilh licmlod <br />contrrclm to comtrucl th€ proiect. <br />Osle Owmr (Sig.) <br />Conlrclon lrt. Only <br />CONTRACTORLln u^-0, an,;-0 . tlAa lrzfi-L /r74-07D7 <br />PHONE <br />E7'*frln fl;*,r--STATE/ZIP <br />--r l XVz o <br />I he,eby affrrm thal I am licens€d under the provisDns ot <br />full lorce and <br />subiet to tho Worker's Compen$tion Laws ot <br />Lodc. To APellcil: <br />ll 8fter makrng thrs Certrficate ot Exemptron, you should become subl@t to the Worker's Compen- <br />satron provrsrons of the Labor Code. you musl torthwdh comply w(h such provrsrons or lhrs <br />permrt shall be dmmed revoled <br />ol Worttr s Com- <br />Verilaed By <br />Oate Applic8nt (Sig ) <br />I t€reby srlirm thal I <br />pensation I <br />thispermat isissued. I shall nolemployany <br />Certilied copy is lilad with the Cily <br />in any mannor so as to <br />t he porformr nce ol the <br />Applicsnt (Sig. <br />Oate <br />Exprres <br />Errrddr <br />This pomit shall expiB by limitslim and bocome null and void it tho wort authorizod by thir <br />pormit B rct @mmncod withan l80 dey6lrom tha dato ol lhiE p€rmit or il work 8uthorized by thi! <br />permil is suspgndod or lbsndoned tt any tim€ attor th€ wort is cornmncod ,or a p€riod ot IEO <br />dayg. A nil ptrmit shsll bo obtain€d lilsl botoro sch wo.t dn bo rocommnced. <br />r csrrry rhar r heve 'Ed rhis appri"",ml:"ffi,f"oo," <br />Applrcant or Agent <br />I agr6 <br />andand@mply with all <br />ot thi8 city toaulhorized <br />purpos6 <br />Plan Check 65%ol subtotat 58.Sc, (minimum 2O.OO) <br />10.00 <br />Rain Water (buried) Ea. 100' <br />DATE t7- <br />Ea. Add'l Outlet <br />Water Service Ea. 100' <br />Repair or Replace Gas Piping <br />Over 2" <br />Backflow Device 2" or Less <br />Owr5 <br />Vacuum Breakers 1-5 <br />Repair/Alt. Drainage or Vent <br />Deck Drain System - Per Drain <br />Gas Service <br />MISCELLANEOUS <br />Water Heater - Electric or Gas <br />Water Piping Ea. 1@' <br />Water Softner <br />ofAlt. or - Vent <br />Lawn Sprinkler <br />- Per DrainRain <br />lnd. Waste lnterceptor <br />Pool <br />1.00 <br />100.00 <br />5.00 <br />5.00 <br />10.00 <br />10.00 <br />10.00 <br />8.00 <br />5.00 <br />4.00 <br />1.00 <br />10.00 <br />s.00 <br />10.00 <br />10.00 <br />3.00 <br />8.00 <br />5.00 <br />(50.00) <br />Date <br />Subtotal <br />Penalty Fee (when applicable) <br />Violation Fee <br />Pc#Receipt lrb.6 <br />Plan Check (Adjuslment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />PERMIT ISSUEO BY (Sig ))(nEUILDING <br />PERMIT No VERI (srg ) <br />LrA &,"- /147q 7o <br />(ACCOUNT 1-1121 <br />Orslribu t lnspector Copy 2 File Copy 3 Frnance Copy 4 Applicant Copy <br />cs-6r r <br />.L^ 'or '' <br />6.00 <br />3 ol the Busan6s end <br />Class <br />Contrector <br />Dclratlon <br />the <br />-O- <br />,