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o o <br />APPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-2738 W <br />APPLICANT FILL IN AREA BELOW <br />(!g <br />7Izo <br />ooI, <br />m <br /><no <br />hlr <br />p <br />[^l> <br />IZ <br />A <br />t; <br />lrh <br />I <br />C <br />Cr3 <br />0'') <br />$\ <br />o <br />lF <br />* <br />l, <br />sANTA {e urt-r-nee O<. # E <br />Ot tg3us) <br />R <br />JOB ADDRESS <br />3bl5 FAtnrlrcO \qo <br />MAILING ADORESS ( <br />(i'i'TtazcCITYc-6\A rf\CSA 1st '100'+Conn.15.00 <br />NO.EACH TOTAL <br />\ <br />FIXTURES <br />Dental Unit or Medical Gases <br />each plumbing fixture/trap 5.00 <br />10.00 <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 100' or Fraction 5.00 <br />Private Sewage Disp. System 30.00 <br />GAS PIPING <br />\5.00GAS SERVICE 1 to 4 Outlets 5eq <br />1.00Ea. Add'l Outlet <br />Repair or Replace Gas Piping 5.00 <br />Om.r{rrlld.r O.dttbn <br />I he.eby atfirm that I am exmpl trom lhe Conlracto/s Lrcss€ Law loi tha lollowing rsam (Str. <br />7@1 5. Business and Professions Code Any city or counly which r6quir6 a pormil to conslrucl, <br />altor. improv6. d€molBh. or rep'ir any structure. prior to its igsuance. als r€quires tho applicant <br />tor such p€rmit lo lile I signed slatemenl thet he is licanssd puf,tu6nt lo tho pmvirion! ot lhe <br />Conlrsctor's Licsns Lan (Chapter 9 (commencing with Section 7m0) ot Oivision 3 ol lhe <br />Busrnoss and Pror6sions @de) o. llst he rs exempl lhorstrom and the ba3i8 lor lhe allog€d <br />oromption AnyvDlalimo,Soclion7001.5byanyappliantlorapermilsubioclsth€applicanlto <br />a civil penslty o, not more lhen ,ive hundrsd dollsE (t5O0) <br />E S.ction 7044A l. as owner ol lh6 property, or myBmployees wrth wa96ss thoirsolecompen- <br />sltion. will do the mrt. and th€ slructure B rcl intmdod or olttrod tor sale. <br />E S*tion 704{8 l. s owns ol the propany. am erclusively conlreting with licmlod <br />conlracto't to conslrucl the goiect. <br />Date Owner (Sig ) <br />100.00 <br />5.00 <br />Conlreioo lraa Only Water Piping Ea. 100'10.00CONTRACTOR <br />tlt€ 4+0,lttcAL *dl LxTt<,N h4 - qto'lPHONE <br />Rain Water Piping (buried) Ea. 100'8.00 <br />Water Softner 4.00t81 El DF-xteB xv€ADORESS I <br />Ah. or Repair of Drainage - Vent Piping 10.00STATE/ZIP <br />d Q-n\oCITYL*fe EL<tNoR€ (a Lawn Sprinkler 6.00 <br />Rain System - fur Drain 10.00 <br />lnd. Waste lnterceptor 8.00 <br />Pool Traps 5.00 <br />I hereby sltirm that I am licen*d und6r the provi3aons ol 3ol th6 <br />Conlractor (Sig.) <br />and <br />is rnCode. and my <br />Deck Drain System - Per Drain 3.00 <br />Repair/Alt. Drainage or Vent 10.00 <br />l 5.00 <br />1.00 <br />I 5.00 <br />10.00 <br />I 10.00 <br />9c <br />"g6aWbnoclr.tbnthat t trave a /anrfrete ol consmt to sll-rnsure. o, <br />subjrct lo the Worker's Compansation Les ot <br />l'otb. fo ApPllcrl: <br />lf atter makrng thrs Cerlrficate of Exemptron. you should become sublsl to lhe Worke.'s Compen- <br />satron provrsrons of the LSbor Code. you must lorthwrlh comply wrlh such provrsons or lhrs <br />permrl shall be demed revoked <br />ol Wo.ker's Com- <br />'7 <br />CalrlornE <br />Oate Applacsnl (Srg ) <br />in lhe p€rlormanca <br />Applicant <br />this parmit is is$ad, lshallnot smployany <br />Cstitied @py is filed wilh the Cilypensalion <br />I hereby aflrrm <br />Oale <br />Expires <br />(s0.00) <br />Vacuum Breakers 1-5 <br />V\hter Service Ea. 100' <br />Orcr5 <br />Over 2" <br />Backflow Device 2" or Less <br />Subtotal <br />Fenalty Fee (when applicable) <br />Violation Fee <br />Plan Check 65% ol subtotal <br />Pc#Receipt Nol <br />Plan Check <br />20.00) <br />Date <br />lssuance Fee <br />TOTAL PERMIT FEE <br />10.00 <br />q <br />@ <br />Temporary Gas Service <br />Water Heater - Electric or Gas <br />MISCELLANEOUS <br />Erdrdon <br />This permit shall oxpare by limitation and b€come null 8nd void it ttE work authorizd by this <br />B nol comm€ncod wilhin t80 days trom the date ol lhis permil tr il work aulhorizod by lhis <br />is susp€nd€d sabendon€d at any time and tho worl is cmmnced lor a p€riod ot 180 <br />A nfl pdmit shall be obtsaned liGl b€lore such work en be recrmmnced. <br />Oate Applicanl or Agont (Srg. <br />Arlolc.nl'! Oadaiatil <br />end stato that lh6 abovecertity lhst I havs rsd this I agrs lo <br />wath all andend strt€ laws to building <br />this city to ents <br />purpos6 <br />-(D- <br />BSAt?iS" 5!63t PERMIT ISSUEO BY (Sr9. <br />PERMIT <br />ALr fe€s ?D. lv-ffi,l l-ial2) <br />,Y) <br />Oistribution: L lnspeclor Copy 2. Flle Copy 3. Finsnca Copy I copv <br />cs-6r 1 <br />UtrResidential ! lndustrial ECommercial <br />q t{ 4,99. <br />SEWER <br />oI <br />I <br />\6s