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a oAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273€N <br />APPLICANT FILL IN AREA BELOW <br />@ <br />E-9zo <br />ool, <br />m(,(, <br />s <br />JOB ADDRESS /! lndustrial E Commercial NO.EACH TOTAL <br />5.00 <br />'10.00 <br />each plumbing fixture/trap <br />Dental Unit or Medical Gases <br />MAILING <br />STATE/ZIP )G SEWER <br />Oun r-Buald.r D.drlba <br />I hereby sltirm lhst I am exompl lrom tho Contracto/s Lrcens Law ,or the lollowing reasm 1Se. <br />7031 5, Businss and Pror6sions Codo. Any city or county which requires a p€rmit lo construct. <br />alier. rmprcw. demolish, or reparr any slructura, prid to rls isuanc6, alsrequiresthe applicanl <br />lor such permil to ,ile a 3igo€d stetemenl lhal he is licensed puBuant to lh€ provitiom ot lhe <br />Conlractor's Licens Lil (Chepter 9 (commoncing with Seclion 7m0) o, Oivisaon 3 ol th€ <br />Eu3iness and Proro3sims Cods) or thst he is oxempl lhsrolrom 8nd tho balb tor lhe sllegod <br />exomption. Any violrtion ol Saction 7@1.5 by any applicanl tor a pormil subiect3 the applicant lo <br />I ciyil penalty ot nol mo.o then tivs hundrod (bll86 (3500): <br />E S*tionZOal l,asown6rollheproperty.ormyemployGswrthwsgaraslhsirsolocomp€n- <br />salion, wall do lhs mrt. and lhe 3truclur€ as rcl antandod or otleed ,or sale. <br />El S*tion 7(x4B l. a3 owner ol the proporly. m oxclusivoly conlreling wilh licffrod <br />conlracloG lo conslruct the prolftl <br />Oate <br />- <br />Owrer (Sig ) <br />ConlrEton t,.. otily <br />tfn /,j1d,",r;-L Allt rrT^;-,SONTRACTOR t7/- /7a7PHONE <br />I <br />CITY A . <br />X, y', f y'n r- -u r-, <br />STATE/ZIP <br />^qr33es <br />I he,eby allirm lhsl I 8m licensd undar the provBions ol <br />ilo(lc To ApellGal: <br />ll aller makrng lhrs Cfrtrftcaleol Exemplron. you should becomesubtel lo lhe Wdker'sCompen- <br />satron provisrons ot lhe Labor Code. you must torthwilh comply w[h such provisions or this <br />permrl shall be dtrmed revoked <br />Erpardo.r <br />ThE pormit shall expiro by limilslim and b*omo null and void il tr€ work authoriz€d by lhig <br />pormit is not commencod wilhin 180 dlyE lrom lhe deto o, lhis p€rmil d il rcrk authorizod by this <br />permil is suspendod or sblndonod al rny tim erts tho work is cmmnc€d ,or a p€riod ol 180 <br />dey3. A ner pormil shsll bc oblained ,iBl b€rqo $ch wort cln b€ ocommoncad. <br />AFlc.all D.drilqr <br />I corliiy lhsl I havo rood lhi! applicalion rnd strls lhal lh€ rbova <br />3ol lhe <br />Vlo <br />Contr8clor (Sig.) <br />ol Works's <br />I agrs to <br />and <br />ryfr";* <br />Lfdnse No <br />Oate <br />Oate <br />Expirei <br />lhis parmil is issued, I shall nol employany <br />to the Worker's Compenstion Laws ol <br />which <br />sub,trt <br />Applicanl or Agenl <br />Applicant <br />Code, and my licens is in lull lorce end <br />D*lr.tlon <br />ol consent lo <br />pensation lnsu.ance Cgtrlied <br />I hereby allirm that I have a <br />rn lhe performencoot th€ <br />in any manrer so rs to <br />Calrlornra <br />comply with all and stale 186 relaling to <br />this city to ontar upon the <br />Dats <br />- <br />Applicant (Sig.) <br />the clty <br />aulhorized <br />purpos6 <br />Alt. or Repair of Drainage - Vent Piping <br />Plan Checi< 65% of subtotal L S - (minimum 20.00) <br />5- <br />,/o <br />10.00 <br />/ <br />/ <br />Subtotal <br />I -, <br />lst 100'+Conn. <br />Wbter Service Ea. 100' <br />Ea. Add'l Conn. <br />Over 2" <br />Ea. Add'l 100'or Frac'tion <br />Backflow Device 2" or Less <br />Private Sewage Disp. System <br />Orer 5 <br />GAS PIPING <br />Vacuum Breakers 1-5 <br />GAS SERVICE 1 to 4 Outlets <br />Bepair/All. Drainage or Vent <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />Temporary Gas Service <br />MISCELLANEOUS <br />Water Heater - Electric or Gas <br />Water Piping Ea. 100' <br />Rain Water Piping (buried) Ea. 100' <br />Water Softner <br />Rain System - Per Drain <br />lnd. Waste lnterceptor <br />fool Traps <br />Deck Drain - &r Drain <br />15.00 <br />30.00 <br />5.00 <br />s.00 <br />5.00 <br />100.00 <br />1.00 <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 />6.00 <br />10.00 <br />10.00 <br />3.00 <br />8.00 <br />5.00 <br />Fee (when applicable) <br />Violation Fee (50.00) <br />DatePc#Receipt No. <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE (minimum <br />PERMIT <br />Lawn Sprinkler <br />il-Y /toroA- 'o'PERMIT ISSUED BY (Sig.)\x-BUILOING <br />PERMIT No.(srg IVERI <br />J*-*- -,,--/ kn.l/1q7o )AiA- Stkt?fl -1- <br />vALTDATTON (OFFTCE USE ONLY) <br />(ACCOUNT <br />'1 <br />1-412) <br />Drstflbulron I 2. File Cogy 3 Finance Copy 4 Applrcant Copy <br />cs-61 1 <br />FIXTURES <br />il <br />4 <br />/a=o - <br />Z9-'- <br />5Y!a <br />a,