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o aAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWBITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273a W <br />APPLICANT FILL IN AREA BELOW <br />@grozo <br />oo! <br />m <br />@ <br />U) <br />l(,^tlip <br />IlvZl-r7 <br />-ha <br />C <br />r <br />o(\ <br />eI <br />h <br />up <br />AResidential Elndustrial DCommercial NO.EACH TOTALJOB AOORESSqniii-s$rrA $e vlutAce DK. 4e <br />FIXTURESdwNER <br />Sur.)sLour-(< AgS(- <br />PHONE <br />sq 6-0 I lo each plumbing fixture/trap IL 5.00 (b% <br />Dental Unit or Medical Gases 10.00(D <br />fE/ztP <br />u <br />LING <br />\3 <br />[\es.A"ccg\a SEWER <br />1st 100'+Conn.15.00 l5s <br />Ea. Add'l Conn.5.00Orna?-Brrlldar D.drdbo <br />I horeby atlirm lhal I am ergmpl trom the Contractor's Lrcms€ Law lo. ths lollowino reason (S€c <br />7@l 5. Bwim$ and Prot6sions Code. Any city or counly which requrrG a permit to construct. <br />altsr, rmprcve. demolish. or repair any struclure, prior lo ils rsuance, als requireg the applicant <br />lor such permit to ,ila I signed stalemonl lhat he E licmsad pursuant to the provisiom ol lha <br />Conlractor's Licens Ls (Chrplsr 9 (commncing with Setaon 7m) ol OivBion 3 ol ths <br />8$iness and Pror6sions Cod6) or thrt ha is exempl thsrerrom aod tho baaE lor lhe allegod <br />oromption. Any violalim ot Saction 7031.5 by 8ny spplicanl lor a permit subiecls the applicant to <br />6 civrl penally ot nol mora than rivo hundr€d (bllaB (t5O0): <br />E EectionTO44A l,asownerotlhoproporty.ormyamployeeswdhwag€!astheirsolocompon- <br />sllion. will do lhe wort. and the slrrclure b not inlend€d or olrssd lor 3ala. <br />E S*tion 7(N48 I, as owns o, tho prcporty. rm erclusryely contiacting wilh licmsGd <br />conlracloB to construct the proie€t <br />Oate Owner (S€ ) <br />ConlrEton t .. orily <br />CONTRACTOR <br />lntr Ut*ttlLh L Aed-t c*nrotl C;t4 - o1o1 <br />PHONE <br />t n1 P I ErTErz- Ave <br />AbDRESS <br />Alt. or Repair of Drainage - Vent Piping <br />\ <br />Ea. Add'l 100'or Fraction <br />Priwte Sanage Disp. System <br />Water Softner <br />Rain Water Piping (buried) Ea. 100' <br />Water Piping Ea. 100' <br />Water Heater - Electric or Gas <br />MISCELLANEOUS <br />Temporary Gas Service <br />Repair or Replace Gas Piping <br />Ea. Add'l Outlet <br />GAS SERVICE 1 to 4 Outlets <br />PIPING <br />5.00 <br />30.00 <br />5.00 <br />100.00 <br />1.00 <br />5.00 <br />s.00 <br />10.00 <br />10.00 <br />4.00 <br />8.00 <br />'"LAL€ ELst A)oR€ <br />PSTATE/ZI <br />^0 2n?o Lawn Sprinkler 6.00 <br />I hereby alfirm lhal I am licensd under lhe provasions of <br />Oate <br />and in lull loce and <br />subiecl lo the Worke/s Compensation Lfrs ol <br />|'olb. Io Afdlcltl: <br />ll atter makrng lhrs CerlricateolExemptron. youshould becomesubi6ttolheWorker'sCompen. <br />salron provrsrons ot lhe Labor Code. you musl lorihwrth comply wdh such provasions or lhrs <br />permrl shall be demed revoked <br />of <br />I ihe <br />copy is <br />Verated <br />Oate Applicant (Sig ) <br />Come.naalbn <br />ol consmt to <br />with tha City <br />I horeby alfi.m that I <br />pensalion <br />Erprres <br />Oate <br />which this permit is issuad, I shall not employ any <br />any mnnef so 0s to <br />Applicant <br />ot lhe <br />Erpa.auc! <br />Thrs pormit thell oxpire by limitaiion .nd beomo null and void il th€ rcrk aulho.iz€d by thi3 <br />p€rmit is rcl commenced wilhan 180days lrom lhe date ol this pormit or il work authdized by lhig <br />p€rmit is suspanded or 0bandongd at ony lime alts the work is commncad ,or 8 period ol t8O <br />days. A nil pdmit shSll & obtained li6t b€tore such work can b€ Ecommanced. <br />I certity that I have lhis Epp[catron and stete thal lhe above <br />Apglicsnt or Agenl <br />Apglc.nl'r D.df,.do <br />I rgre <br />and st6to law3 rolatino to@mply with all <br />ol this cily toauthorizod <br />purpos6 <br />oo <br />10.00 <br />10.00 <br />10.00 <br />8.00 <br />10.00 <br />5.00 <br />5.00 <br />3.00 <br />'r.00 <br />10.00 <br />5.00 <br />Rain System - Fer Drain <br />llhter Service Ea. 100' <br />lnd. Waste lnterceptor <br />Over 2" <br />Pool Traps <br />Backflow Device 2" or Less <br />Deck Drain System - Per Drain <br />Oler 5 <br />Repair/Alt. Drainage or Vent <br />Vacuum Breakers 1-5 <br />Subtotal <br />TOTAL PERMIT FEE <br />Fenalty Fee (when applicable) <br />lssuance Fee <br />Violation Fee <br />Plan Check 65% ol subtotal <br />#Receipt l.l,o. <br />Plan Check <br />(50.00) <br />(minimum 20.00) <br />Date <br />(sig.) <br />NG <br />No.ruw PEBMIT ISSUEO AY <br />s tPD [f) -LL <br />Y) <br />t-4121 <br />777o ? <br />Oislribution: I lnspector Copy 2 File Copy 3. Finance Copy 4 Appli <br />cs-6r I <br />bAb <br />t4 <br />Contrector (Sig