Laserfiche WebLink
o oAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-2738 <br />APPLICANT FILL IN AREA BELOW 4 <br />(Dg-ozo <br />oof, <br />mo <br />at, <br />N <br />\ <br />R <br />-T?6V ,ln-,*,, .7, ,lJ;-u.r-,.,.- *E <br />STATE/ZIP2bz a <br />PHONE <br />o <br />MAILI <br />CITY <br />il 5.00 <br />10.00 <br />NO.EACH TOTAL <br />5 <br />D lndustrial ll Commercial <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 />1 st 1 00' + 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 s- <br />Ea. Add'l Outlet 1.00 <br />Repair or Replace Gas Piping 5.00 <br />Orn r-Butld.r D.drdbil <br />I harsby Itlirm that I !m sxempl lrom lhe Conlractor's Licen3o Law lor the rollowing rgason (Sac. <br />7qjl.5. Busrness end Proressaons Code. Any caty or county which roquirss a pormil lo conslruct. <br />aller. improve. d€moliEh. or replir lny 3lrucluro. prior lo rts r$uance. allo roquirag lh€ applicanl <br />tor sch pormil lo ,lle a signod 3tllamoil thal hs B licon3ed pursuant to lho provisions ot lho <br />Contrscttr's Licens Law (Chlplor 9 (commencing with Saction 7CD0) ot DivBion 3 ot lho <br />8u3inN and ProlesEron3 Code) or lhst ho is axmpl thererrom and the basis ,or lho dbgod <br />exmplion. Any yiolalion ol S€cllon 7031.5 by any applicrnl tor 6 pormit 3ubiecB tho lgplicanl to <br />8 civil pemlty ol nol more lhan five hundrod dollaB (t5@): <br />E SoctionTO44A l,r!o*n6rorlheproporly.dmyemplol€Bwilhwag€saslheir3olacompon- <br />3ation, wrll do the wort. and tho strrclure is nol rntend€d or ottorod lq s!le. <br />E S."fion 7Oa4B l, as owner o, lhe proporly. am axclusivoly conlrrcting with licsnsad <br />conlracloB lo con3lruct th€ proisct. <br />Oaie Owrer (Sig ) <br />Cont?rto[ t rc Only <br />W)) -,' Lz /1J,(t Lzafi-,,-.t 67/-oza7 <br />PHONE <br />ADDRESS <br />STATE/ZIP <br />I he.6by altirm that I am licensad undor lhe provisDns of Chapld 9,3of the <br />Code and etlecl.Probssrons <br />Vfl,A" <br />Conlractor (Sig ) <br />license is <br />Class <br />Notc. To Appllcrl: <br />ll atler makrng lhrs Cefirficate of Eremplron. you should become subl6t to the Wo.ke/s Compen- <br />salron provrsrons ot ll€ Labor Code. you must lorthwrth comply wrth such provisions or this <br />permrt shall be deemed revoked <br />Brlrdoi <br />This permit shall expiro by limitltion rnd bocome null and void il the wort eulhorizcd by thi3 <br />pormit is not commonced within 'lE0 d8ys lrom th€ dato ot thi! parmit or il work aultro(i2€d by this <br />permit i3 3uSponded o abandoned at any time attei tha wort is cornmnced lor a poriod ot 18O <br />A nw psmit shall be obtain€d tict b€rore such work can bo ncommonced <br />Aplcrnlt Dodrdor <br />I csniry thal I het/€ read lhB spplicalion snd !i.to thel the sbov6 intomdiql <br />ol Worker's <br />I 89r* to <br />tn <br />Applicent or Agonl <br />O8te Applicant (Sig ) <br />Oclrallon <br />subisct <br />Applicsnt (SiO.) <br />ofthe <br />in eny manner I a to <br />Calilornra <br />wrth all and slate building <br />lhethrs ciy lo <br />I hereby attrrm thel I hsva I ol consont to selt-insure- <br />pensatron lnsurance.copy rs liled with lh€ City <br />Verilied <br />this pormil rs issued. I shsll notemployany <br />to the Worker's Comp€nsalion Lils ol <br />Oate <br />Exprres <br />Ah. or Repair of Drainage - Vent Piping <br />Temporary Gas Service 100.00 <br />10.00 <br />Subtotal <br />Water Heater - Electric or Gas <br />We[er Service Ea. 100' <br />Water Piping Ea. 100' <br />Rain Water Piping (buried) Ea. 100' <br />Backtlow Device 2" or Less <br />Water Softner <br />Over 5 <br />Vacuum Breakers 1-5 <br />Lawn Sprinkler <br />Rain System - Per Drain <br />lnd. Waste lnlerceptor <br />Pool Traps <br />Deck Drain System - Fer Drain <br />Repair/Alt.or Vent <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 />5.00 <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 <br />Plan Check 650/o of subtotal <br />Pc#Receipt No <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />(s0.00) <br />Date <br />(minimum 20.00) <br />(minimum <br />PERMIT <br />Over 2 <br />DATE S'/ 7. <br />)l,0r-BUILOING <br />PERMIT No ilhaC (srg )PERMIT ISSUED BY (Sig.) <br />L-- -.-,)-2 d-vt. tuil?7.> 1l10/tL .<.ll.ggdJj - <br />,vALroATroN (oFFrcE usE oNLY) <br />(ACCOUNT rr r-4r2) <br />O'st 'tl Copy 2 Frle Copy 3 Frnance Copy 4 Applrcanl Copy <br />cs-6r r <br />--1 <br />Y <br />,1 <br />5- <br />E-- <br />,/b - <br />'^- <br />5