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o oAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273a M <br />APPLICANT FILL IN AREA BELOW <br />(Dg-Izo <br />oo! <br />m <br />U) <br />U' <br />t,tJ <br />a <br />V:) <br />n <br />E <br />ldtIlo <br />F <br />ls <br />Ffi <br />.{Residential Dlndustrial ECommercial NO.EACH TOTALJOB AOORESS5I \O SANaA fe utuuned p<4F <br />FIXTURESOWNER <br />Sur.y0 uoocr- AgSoc-5t16-6t/o <br />PHONE <br />each plumbing lixture/trap 5.00 45!4 <br />MAILING ADDNESS Dental Unit or Medical Gases 10.00 <br />ITY <br />2GmcgA 1st 100'+Conn.15.00 <br />Olni€uflaLr D.drdbn <br />I hereby affi,m lhat I am €xempt lrom the Contraclo/s Licen3e Law tor tho tollowing reason (S€c <br />TCKil.5, Busrn$s and Prolcsons Code. Any cily or county which r6quirgs a permit to construct, <br />aller. rmprove, demolish. or repalr any slruclure, pror to rts rssuance. al$ requirB lhe rpplionl <br />,or sch permil to lile a signed 3latem6nl lhat he is licens€d pureuanl to the provisiom ol the <br />Contractor's Lrcense Lil (Chapter 9 (commencing with S€ctron 7O0) ot Oivision 3 ol lhe <br />8Brnffi rnd Prot6sron3 Cod6) or that h€ as gxempt theretrom and the ba3a! tor the allaged <br />eremption Any violalron ol Soclion 7031.5 by sny applicant lor I permil subisE the spplicanl to <br />a crvil p€nalty ot not more than tiva hundred dollaB (35@) <br />E S*tion 7(X4A l. as owner ot the properly. ormyemploy*s walh wag6s lheirsolecompen- <br />lation, will do the urort.6nd lhe slruclure is rcl inlondod or ortared tor sale. <br />E S."tion 70448 l. as ownd ol th6 proporly. am exclusiv€ly contractang walh liconld <br />Ea. Add'l Conn.5.00 <br />Ea. Add'l 100' or Fraclion s.00 <br />Private Salage Disp. System 30.00 <br />GAS PIPING <br />GAS SERVICE 1 to 4 Outlets 5.00 5 <br />Ea. Add'l Outlet 1.00 <br />Repair or Gas 5.00 <br />conlracto6 lo construcl the p.ojsl <br />o.te <br />- <br />owmr (srg ) <br />Temporary Gas Service 100.00 <br />MISCELLANEOUS <br />Water Heater - Electric or Gas 5.00 gr <br />Contre.|or lrao Only <br />Water Piping Ea. 100'10.00 <br />L+t c L Rain Water Piping (buried) Ea. 100'8.00 <br />AOORESS Water Sottner 4.006L <br />Cl STATE/ZIP Alt. or Repair of Drainage - Vent Piping 10.00 <br />Ls 2_,1o Lawn Sprinkler 6.00 <br />I heroby artirm that I am licensed und€r lhe provisrons ol Chapts 3ol lhe Busrn6sand Rain System - Per Drain 10.00and my lrcen*tull b lnd. Waste lnterceptor 8.00 <br />Contractor Pool Traps 5.00 <br />Deck Drain System - Fer Drain 3.00 <br />Com9.rilalbn O.clfdlon Repair/Alt. Drainage or Vent 10.00 <br />I h€reby allirm thal I corliti@t€ ol consent to sll-insure.o,Com- <br />pensatron copy rs liled wilh lhe City Vacuum Breakers 1-5 5.00 <br />Oate <br />Exprres Over 5 1.00 <br />Applicant (Si9 ),Backflow Devic,e 2" or Less s.00 <br />tn permil is issued. lshall rct 6mployeny Over 2"10.00in any mannar I s subiacl to the Workor's Compenstion Laws ot <br />Calrlornra Water Service Ea. '100't 10.00 <br />Oero <br />- <br />Applicrnt (SiO.) <br />t{olb. To APflllcil: <br />ll atler makrng lhrs Cerlrfrcate of Eremplron. you should become sub,rcl to the Worker's Compen- <br />provrsrons ot tlE Labor Code. you must lonhwith comply wilh such p7oi8im3 or thE <br />shall be dem€d .*oked Subtotal <br />Penalty Fee (when applicable) <br />Erpardo. <br />This po/mit sh6ll expira by limitation and bocome null and void it llE work autho.izod by thi3 <br />tErmit it not commnced within 180 days trom the dat6 ol thir pormit or il work suthorizod by thi3 <br />parmil ir suspend€d or abendonod al any timo arter lhB wort is comrnoncod ,or s ,prbd ol IEO <br />day3. A n* pe.mit Shall be obtainsd liBt b€rore such worl can bc mmmcad <br />Violation Fee (50.00) <br />Plan Check 65% of subtotal (minimum 20.0O) <br />Receipt No.Pc#Date <br />I carrity thar I hav6 read thi3 Epp,,""rffi:;ffifl"u*"I agr€€ lo Plan Check <br />comply with all 8nd state laws to and lssuance Fee 10.00authorizad <br />purpos. <br />this cily lo ents <br />TOTAL PERMIT FEE <br />Applic8nt or Agsnt PERMIT <br />EUILOING e <br />PERMIT PEHMIT ISSUED BY ) <br />At-U fGTS P r-(ACCOUNT t-'t12) <br />() <br />ltear <br />772 o <br />Orstrbutron 1 lnspeclo. Copy 2 File 3 Finance Copy 4 copy <br />cs-6r r <br />SEWER <br />l Soq <br />\ <br />I <br />-5s- <br />---E6-\)..- <br />-Tos- <br />n-os <br />RD <br />(