Laserfiche WebLink
t ,o <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W 4th Street <br />667-273a k- <br />APPLICANT FILL IN AREA BELOW <br />(!g-q <br />zo <br />oo! <br />ma <br />@ <br />I <br />tlr <br />lo <br />[,t>lz <br />l-lt> <br />l- <br />P <br />I <br />IC <br />F <br />a <br />(r\ <br />LO <br />ln <br />Ir <br />bh, <br />I <br />JOB AOORESS3? I o sANTA <br />+A€e Uf \-Ln6€ 0( <br />OWNEFI <br />SUNfLO(r)CT( ASS(-,sqGrot\oPHONE <br />MAILING ADDRESS \"35\5- sRrRureo Ro <br />NO.EACH TOTAL <br />5.00 <br />10.00 <br />each plumbing fixture/fap <br />Dental Unit or Medical Gases <br />CITYcos-rh r\esA t{'l''q L;AG t 't5.001 st 1 00' + Conn. <br />Ea. Add'l Conn.5.00 <br />l5s <br />Ea. Add'l 100' or Fraction s.00 <br />Private Sewage Disp. System 30.00 <br />GAS PIPING <br />GAS SERVICE 1 to 4 Outlets I 5.00 ;i9 <br />1.00 <br />5.00 <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />Orn t-ldld.t O.dtttbn <br />I hereby altrrm lhal I am exempt lrom tlE Cotraclo/s Lrcons Law tor tho tollowing r€aon (Soc. <br />7031 5. Bu3ine$ and Professions Code. Any city or county which requiros a permil lo construct. <br />aller. rmprove. demoligh, or repair eny slruclu76, prior to its isuancs, allo requii$ lh6 applicanl <br />lor $ch perml lo lile a signed 3tatgm€nl thel he is licms€d puBuanl lo lh€ prcvi8iom o, lha <br />Conlractor's License L8w (Ch@tor 9 (comm6ncing with S€ction 7@0) ol Oivision 3 ol lhe <br />Busrnoss and Pror6sioo3 Codo) or lhal he is exampt th€rolrom and lh6 basB lor th6 all€96d <br />gxsmplion AnyvaolationorSectionT03l.SbysnyapplicantrorrpermitsubiecBtheapplicantto <br />e civil p€nally of nol more lhan lavo hundted dollars (3500): <br />E S*tion ZOgl l. as ownorot tho properly, ormyemployeeswrth waga6 as thoirsol6compon- <br />salion. will do lhe mrt. and the structuro is not intend€d or ot erod ,or sale. <br />E S""tion 70448 l. s9 own6r ol th€ prcperly, 8m oxclusryely contraclang wilh licensod <br />conlractoE to conslruct the proi*l <br />Dare <br />- <br />Owner (Srg ) <br />Conlrclon tl. Only <br />CONTRACTOR*i,eut*t tchL xmlt zaqott)L14 - o1s1 <br />PHONE <br />l9tpl Mxwz Aue <br />ADORESS <br />CITYLXfe 6 Lst ^tr€ <br />STATE/ZIP4aa% <br />I hereby alfirm lhsl I am licmsed under the provisions ol Chapter 3 ol lhe Eusrn6s and <br />b <br />Contractor <br />Code. and my is in tull eflffl <br />subiel to tho worke/s Comp€nslion Lils ol <br />ilo0o To ArDllcrl: <br />ll aller making thrs Cenrftcale of Exemptron, you should become sublsl to lhe Workeas Compen- <br />satroo provrsrons ot lhe Labor Code. you musl lorthwrlh comply wilh such provrsrons or th,s <br />permrt shall be demed revoked <br />Calalornia <br />Dale <br />Exprres <br />I <br />Dsle <br />- <br />Applicent (Sig.) <br />ol Woita,'s Com- <br />the crtypensationCertilied copy rs <br />Vontred By (Srg. <br />Applacant <br />lhe perrormance whichthis parmit is issued, I shall nol employany <br />I hereby allirm that I have <br />Erplrddr <br />ThB pormit shsll oxpiro by limitslim and become null and void il the rcrk aulho.iz€d by lhis <br />psrmil is nol commanced within tA)diys lrom tho data ot this pormit d il rcrt sulhorized bythis <br />pormil B suspanded or ebendonod at any tima atlar th6 wort is commnc€d ,or a p€riod ot 180 <br />d!ys. A nil p€rmil 3hall b€ obteined ,iBt belore $ch wort en bo rscommencod. <br />AFlc.nl'. O.drdon <br />I cortity thst I hays rold lhis applicalim 8nd 3lrls that the lboyo I agr6 lo <br />andand stato rslatano locomply with 8ll <br />thas city lo enls <br />Apphcanl or Agsnl <br />aulhorared <br />DUr@36 <br />Alt. or Repair ol Drainage - Vent Piping <br />10.00 <br />100.00 <br />cg <br />II <br />Oc)Subtotal <br />OATE o' <br />Temporary Gas Service <br />M/ater Service Ea. 100' <br />MISCELLANEOUS <br />Over 2" <br />Whter Heater - Electric or Gas <br />Backflow Device 2" or Less <br />Water Piping Ea. 100' <br />Over 5 <br />Rain Water Piping (buried) Ea. 100' <br />Vacuum Breakers 1-5 <br />Water Softner <br />Rain System - Fer Drain <br />lnd. Waste lnterceptor <br />Pool Traps <br />Deck Drain System - Per Drain <br />Repair/Alt.or Vent <br />s.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 />s.00 <br />Fee (when applicable) <br />Violation Fee <br />Plan Check 65% of subtotal <br />Pc#Receipt <br />Plan Check <br />lssuance Fee <br />TOTAL PERMIT FEE <br />(s0.00) <br />(minimum 20.00) <br />Date <br />(minimum <br />PERMIT <br />Laivn Sprinkler <br />PERMIT ISSUED BY (SigEYA.-"?YS51bLJ ,ER,F <br />ALL €res fo oN) m 7 770(ACCOUNT fl ,-41 <br />Orstnbutron 1 lnspector Copy 2. File Copy 3. Frnence Copy 4. Applrcanl Copy <br />CS-61 I <br />(Residential Elndustrial DCommercial <br />FIXTURES <br />(\3'o94 <br />SEWER <br />t <br />Comp.fr.lbn Dclrdbn <br />ot <br />)