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I Resaentiat E lndustrial E Commercial NO.EACH TOTALJOe aoox€ss31 to EAN-IA f€ UILLAGC 9R.D+ <br />FIXTURESOWNER <br />Solr$tOWcr AS'SOC Stl6- Ot t O <br />PHONE <br />each plumbing lixture/kap \\5.00 55- <br />Dental Unit or Medical Gases 10.0033\ S .elrnuicr^l B.D <br />MAILING ADOHESS <br />SEWERCITYGC6-TA NtgA 'ifi''{,c-arc <br />Orm.r-&dl(br O.drtbn <br />I hereby attirm thal I am ermpl lrom the Conlracto/s Licmta Law lor ths ,ollowing ro8on (S€c. <br />7031 5, Businoss and Prol6sion3 Cod6. Any city or county which requires a p€rmit to conslrucl. <br />alter, amprovs. d€molbh. or rapair eny slruclure. prior to it3 isuanca. also roquireS lhe apdicant <br />,or such p€rmit to ,ile a sagnod slatemenl lhal h6 i3 licansod puBuant lo lhe prcvisiom ol lhe <br />Contractor's Licens Law (Chaplar I (commencing wilh S€ction 7@) ot Oivision 3 ot tho <br />Business and Pror6sions Crdo) or tMt he is sxompt th€ialrom end the b8is ,or tho alleged <br />exmpton Anyviolst,onotSoc{ionTO3l.5byanyappliclnllorapermitsbiocl!lheepplicanlto <br />t civil penalty o, not more than live hundr€d dollars (ts(x)): <br />E S*tion Zolll l. as flner ol the property. or myemplorr€swithwag€sas thoirsolecompon- <br />calion, wrll do lho mrt. and lhg strt clure is nol inlendod or orlared lor sale. <br />E S."tion 70448 l. as ownsr ot tha piop6ny, am erclusively conlrrcting with licansod <br />conlracto.s lo conslruct the prolel. <br />Oale <br />- <br />Owner (Srq.) <br />5.00 <br />1st 100'+Conn. <br />Waler Heater - Electric or Gas <br />Ea. Add'l Conn. <br />MISCELLANEOUS <br />Ea. Add'| 100' or Fraction <br />Temporary Gas Service <br />Private Sewage Disp. System <br />PIPING <br />GAS SERVICE 1 to 4 Outlets <br />Ea. Add'l Outlet <br />Repair or Replace Gas <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />5.00 <br />100.00 <br />1.00 <br />5.00 <br />Conlrdoil t .. Only <br />CONTRACTOR <br />ln F CltAtA L kL SnLt ca.rl<ttl <br />PHONE <br />/ Lta -o1o1 <br />lP-lfl AexteL Lv€ <br />IAOORESS <br />CITY ltrr f Lst Ng'.€ cA ^ 42i9oSTATE/ZIP <br />I hereby alrirm that I 8m licensod undet <br />Conlrector <br />tnCode, and my license <br />,rac".*-erbnDct abn <br />I hereby slrrrm thSl I hgve rt€rlilr@te ol @nsenl to slf-rnsure, o, <br />subiecl to the Worker's Compenstion Laws ol <br />tlo0c. To ApP0c.tt: <br />ll6fter making lhis CtrtrricaleolExemplion. youshould b€comsubiEllo theWdk6/sComp€ft <br />sll|on provisrons ot the L8bor Code. y@ must lorthwith comply wlth such prfl6i6s d this <br />permit shell be dsmed r*oked <br />with the City <br />permil is issued. I shall nol employ any <br />ot Wo,ker's <br />p€Gon in any mnmr s 8!t <br />Calitornra <br />Oate <br />- <br />Appli6nt (Srg.) <br />Att. or Repair of Drainage - Vent Piping <br />l <br />I <br />10.00 <br />10.00 <br />8.00 <br />10.00 <br />4.00 <br />5.00 <br />10.00 <br />1.00 <br />6.00 <br />5.00 <br />10.00 <br />10.00 <br />8.00 <br />3.00 <br />5.00 <br />Water Piping Ea. 100' <br />Water Service Ea. 100' <br />Rain Water Piping (buried) Ea. 100' <br />Over 2" <br />Water Soltner <br />Backflow Device 2" or Less <br />Oler5 <br />Lawn Sprinkler <br />Vacuum Breakers 1-5 <br />Rain System - Per Drain <br />Repair/Alt. Drainage or Vent <br />lnd.' Wbste lnterceptor <br />Deck Drain System - Per Drain <br />Pool Traps <br />Subtotal <br />TOTAL PERMIT FEE <br />Fenalty Fee (when applicable) <br />lssuance Fee <br />Violation Fee <br />Plan Check 65% of subtotal <br />#Receipt No. <br />Plan Check <br />(50.00) <br />(minimum 20.00)gL <br />(o oate <br />ErpHdt <br />This p€rmit shall axpire by limatetim and b€come null and void it the rcrk authtrizod by this <br />permil is nol @mm€ncd within 180 days lrom lh6 date ol this pormit or il rcrk au0rtrizsd by this <br />p€rmil is suspend€d or rbandonod ,t any trmo arlr lho worl is cmmncod tor a FErbd ol 18[) <br />days. A nfl ptrm,t sholl be obtsinod tiBt b€tor6 such wort can be @mmncod. <br />I certiry that I hava r6d thr rpp,,-,ffi:;ffir*, <br />and <br />Oate Applicant oi Agent <br />I ag.e€ to <br />comply with ell city ordinancs and state lews to building <br />lhis city lo entsraulhorized <br />pu.pos6 <br />BHAlli$" <?6 O ,,.,8Y PEBMIT ISSU€O BY (Sig <br />Au- fecs PD <br />,1 t-ata <br />Y) <br />11 <br />inanca Copy i( <br />- <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />'} <br />o <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273a /W <br />APPLICANT FILL IN AREA BELOW <br />(!g-Izo <br />ool, <br />ma(t <br />lcIJ <br />lo <br />I <br />I a <br />d <br />-l <br />-{-,a <br />9r <br />6\\ <br />or <br />+ <br />D <br />Oistribution l. ln3pector Copy 2. Fil6 Copy <br />cs-61 1 <br />I t* <br /><e <br />I <br />(minimuq.l3!.00) <br />-Ss- <br />-@- <br />-roE- <br />tcos <br />looo-5 <br />I )lIt <br />ffi <br />_/