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JOB ADDFESS'3'1ib sAN-iA fe u\uuRee Prt.#c- <br />t^)}J€LO(r)ea F6SOE <br />OWNER <br />5q6- ot t0 <br />PHONE <br />s3l5 rni<uied KD, <br />MAILING ADDRESS <br />Fil?iiazc <br />CITY c-os-TA fnesA <br />Our.r-Add.r O.dr.abo <br />I hereby alrirm that I am exmpt lrom the Contracio/s Licmse Law lor the lollowing reasofi (Sec. <br />7q3l 5. Busines and Prot6sions Code. Any cily or county which raquires a permit lo construct. <br />elte., rmprove. dgmolbh. or rgplir any strucluie, prior lo its isuanc€. al$ roguires tha Spplienl <br />lor such permil to tile a signed stalemonl thal he E licenlod puEuanl to lhe provisions o, lhs <br />Conlrsclor's Lrcen!€ Law (Chapler 9 (commencing with Soclion 7mO) o, Oivision 3 ol tho <br />Busino$ and Prote3siof,s cod€) or lhel he iB exGmpt tlBrarrom and lhe basis lor the allog€d <br />aramplaon. Any vlolatlon ot Soclion 761.5 by lny applicanl lor I p€rmit sbjacts the applicsnt to <br />a civil penalty of nol more lhan fiv6 hundrod dollsB (t5@) <br />E S*tlon lOaA l. as owner ol the properly. ormyemployoeswilh wag€s aslheir sola compon- <br />3alion. will do lhe rcrt. end thc slrElure is not intend€d d ollsed ,or $le. <br />E S*fOn 7O&tB l. a ownd ol the prop€rty, am arclusively cmtrrting with liconsed <br />contraclo6 to construct tho proiecl <br />Oale Owner (Sig ) <br />Conlrelon t,3. Only <br />Lza - oto'r <br />PHONE <br />E lndustrial n Commercial NO.EACH TOTAL <br />FIXTURES <br />each fixture/trap \5.00 <br />Dental Unit or Medical Gases 10.00 <br />SEWER <br />lst 100'+Conn.15.00 <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 100'or Fraclion 5.00 <br />Private Seurage Disp. System 30.00 <br />PIPING <br />GAS SERVICE 1 to 4 Outlets 5.00 <br />Ea. Add'l Outlet 'I .00 <br />Repair or Replace Gas Piping 5.00 <br />Temporary Gas Service 100.00 <br />Water Heater - Electric or Gas 5.00 <br />Water Piping Ea. 100'10.00 <br />Bain Whter Piping (buried) Ea. 100'8.00 <br />Water Softner 4.00 <br />Alt. or Repair of - Venl 10.00 <br />Lawn Sprinkler 6.00 <br />Bain System - Per Drain 10.00 <br />lnd. Wasle lnterceptor 8.00 <br />Pool Traps 5.00 <br />Deck Drain System - Per Drain 3.00 <br />Repair/Alt. Drainage or Vent 10.00 <br />Vacuum Breakers 1-5 5.00 99 <br />Owr5 1.00 <br />Backflow Device 2" or Less I 5.00 o<) <br />Over 2"10.00 <br />Waler Service Ea. 100'10.00 <br />Subtotal teo <br />Penalty Fee (when applicable) <br />Date <br />10.00 <br />CONTRACTOR <br />n ici * tt tc <br />^ <br />L hrplt e*noit <br />R <br />bo <br />I he.aby atlirm lhal I am licensd under the provisions ol Chspler <br />subiecl lo the Worke/s Componslion Lils ol <br />taooc. To ADelbit: <br />ll aller makrng thrs Certrficale ot Exemptron, you should become sublftt to lhe Wo,ker's Compen- <br />provrsrons ol the Labor Code, you must forthwfh comply wnh such p,ovrsions or thrs <br />3ot the <br />Code. and rs rn fullPrddsions4l iloLrdens*tto <br />Com- <br />Veriried <br />Oale Applicsnt (Srg. ) <br />Contractor (Sig. <br />Coflrpadalbn Dclratlon <br />I lEreby sllirm thal I <br />pen$tion <br />Erprres <br />Oate <br />permit is b8ued. I shell rcl gmployany <br />ol consanl lo *ll-rnsure. <br />copy rs filod wilh tho Crty <br />Applicant (Sig. <br />in the p€rlormarcaolth€ <br />rn eny manner I a to <br />Calrtornra <br />fErmil shall be demed ,evoked <br />Erpardo.t <br />ThB pormil shall oxpire by limitstim and become null rnd void it lh€ wort luthotiz€d by lhi! <br />p€rmil is not commsncod wilhin I 8() d!y3 ,rcm the dato ot thi! permit or i, work luthtrizod by lhig <br />pormit i3 cusp€nded or abandonod at any timo atlor tho work is commncad tor s Eriod ot 180 <br />days. A nil pormil 3h!ll bo obtrin€d ti'Et batore arch wort cln bo mmmonced <br />AFlcdl D.Crao.r <br />I certity that I have red this applicalion and state that lhe abovo inlo.mataon <br />and <br />Applacant o, A96nt (Sig.) <br />and state lamcomply wrth 8ll to burldinO <br />this city lo anler upon <br /># <br />Violation Fee <br />Plan Check 65% ol subtotal <br />Receipt No. <br />Plan Check <br />lssuance Fee <br />TOTAL PERMIT FEE <br />DATE <br />(s0.00) <br />olL (minimum 20.00) <br />PERMIT ISSUEO BY <br />ALt f€cs 9P rn 777o't-41?. <br />e IAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-27fi /W <br />APPLICANT FILL IN AREA BELOW <br />Z-lP <br />rr <br />o <br />t <br />o <br />aDrstnbutionr 1. Inspector Copy 2.3 Frnance Copy Gopy <br />CS-61 I <br />(Dgrozo <br />oof,maU' <br />Iu <br />r{\gt' <br />I 15v <br />\.5e <br />MISCELLANEOUS <br />I se <br />I <br />I <br />4 <br />etttrt