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o IAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W 4th Street <br />667-273a <br />APPLICANT FILL IN AREA BELOW <br />(D <br />E-Izo <br />ool, <br />m <br />U) <br />U) <br />s <br />n <br />JOB AOORESSa?oq SAtrmA fe utcucC DK,E# <br />s,.rrrrfuou.te.t< A sso(-OWNER <br />5q6-0rro <br />PHONE <br />Ssls fqtnutca., 'RD <br />MAILING ADORESS <br />"''brrstn Mesn U',''Tzc2c <br />NO.EACHD lnduskial fl Commercial <br />5.00 <br />10.00 <br />each plumbing fiLture/trap <br />Ea. Add'l 100'or Fraction <br />Dental Unit or Medical Gases <br />Ea. Add'l Conn. <br />SEWER <br />lst 100'+Conn.15.00 <br />5.00 <br />5.00 <br />ftivate Sewage Disp. System 30.00 <br />GAS PIPING <br />GAS SERVICE 1 to 4 Outlets I 5.00 6cD <br />O$r.r-lu[.br D.drrfbn <br />I heraby alrirm thal I am exempt ,rom lhe Contractor's Lrcms Law ,or the lollowing reson (S* <br />7(El 5, Bugrna$ and P.ol6srons Code. Any city or county which requires a permit lo conslruct. <br />alter. rmprove. demolish, or .epaar eny slructure. pfltr lo its rsuance. al$ requires the applient <br />lor such permrl lo lile I signed stet€monl thsl h6 is licensad puBuanl to lhe provisions o, the <br />Conlrsclois Lrcens Lrw (Chepter 9 (commencrng w,th Setaon 7(m) ol Davision 3 ol the <br />Business and Prol6sions Code) or that he ig erampt lhorelrom and lhs basis tor th€ allegod <br />exemption Any violalion ot S€clion 7G3l 5 by 8ny applicanl tor I pormil sb,els lhe applicant to <br />8 civil penslly ol not moie than live hundred dollec (35@) <br />E Section 7Oa4A l, a3 ownor ol the prop6ny. ormyomployoeswrth wag6 I lheir solecompen- <br />galaon. will do the $ork, and tho struclurg is not ,nt6nd6d or otlorod tor sela <br />El S*rion 70448 l. as omer ot lhe proporty. am €xclusively contmling with licsnsed <br />conlradoB lo construcl the prolrct <br />Date Owner (Srg ) <br />ConlrEton t,!. Only <br />'llli3'ibn, )tu L fWirsri r/^?*0707PHONE <br />2 o <br />that I am licensd un@. tha provisaons ol Chaptor 9. <br />subiocl lo the Worker's Comp€nsation L*s o, <br />Noilc. To ADPllcrl: <br />ll atter makrng lhrs Cerlrtcate ol Exemplron. you should become sub,ftt to the Worker's Compen- <br />ion provrsrons ol th€ Labo. Code. you musl lorthwath comply wath such pr@6ons o, thig <br />3ot lhe Busr <br />Worker's Com- <br />shall be dEmed revoked <br />ettrct <br />3 <br />Verified <br />Contiactor (Sig ) <br />Clss <br />Date Applicsnt (Sig.) <br />I hereby allirm <br />penstron I copy is liled with <br />Calilornaa <br />Applicant (Sig.) <br />r n t he perrorma nce ol the <br />in eny menner s s to <br />this permit is issuad, I 3h8ll not 6mployeny <br />I heve a of consent to sll- <br />Date <br />Expires <br />Erpardo.r <br />ThB p.rmit shsll sxpire by limitetion tnd bGcoms null and void rl tho wort lutho.irod by thi3 <br />permil is rct @mmanced wilhin 180 days trom lhe date ot this p€rmit or il wort authoriz€d by thii <br />lErmit is $sponded d abandonod al 6ny lim atlor lh€ wort is cmmncod lor e potbd ol l& <br />days. A nd !trmil 3h8ll be obtain€d lir3l botors such worl can be Ecommncod. <br />r c€rr,y rhet rhsvs ro.drhisappri"r,m*ffi;*I agrs lo <br />the <br />Applicanl o, Ag6nl <br />comply wrth all crty and stata lsws releting to <br />ot this city lo entdauthorizod <br />purpos. <br />Device 2" or Less <br />10.00 <br />C.$L <br />a) <br />o <br />Ea. Add'l Outlet <br />Temporary Gas SeMce <br />Repair or Replace Gas Piping <br />1.00 <br />100.00 <br />5.00 <br />Water Heater - Electric or Gas <br />Owr5 <br />Water Piping Ea. 100' <br />Vacuum Breakers 1-5 <br />Rain Water (buried) Ea. 100' <br />Water Softner <br />- VentAlt. or Repair of <br />Lallrn Sprinkler <br />System - Per Drain <br />lnd. Waste lnterceptor <br />Pool 1?aps <br />Deck Drain System - Per Drain <br />or VentRepair/Alt. <br />5.00 <br />10.00 <br />10.00 <br />10.00 <br />8.00 <br />5.00 <br />4.00 <br />1.00 <br />10.00 <br />5.00 <br />6.00 <br />10.00 <br />10.00 <br />3.00 <br />5.00 <br />Orcr 2" <br />Water Service Ea. 100' <br />Subtotal <br />Penalty Fee (when applicable) <br />Violation Fee <br />Plan Chec'k 650/o of subtotal <br />Pc#Receipt M. <br />Plan Check (Adiustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />DATE <br />(s0.00) <br />(minimum 20.00) <br />Date <br />O?y*ilyl,b?Gl <br />^* <br />(sig )PERMIT ISSUEO 8Y (Sig O. <br />fees Pb. oru \q 20 <br />1-1121 <br />/Yl <br />Orstrbulron t Copy 2 Fila Copy 3 Frnance Copy 4 Applrcsnt Copy <br />a- <br />CS-61 1 <br />roraY <br />FIXTURES <br />q Ll 5u <br />I t3@ <br />8.00 <br />l <br />No <br />and my lcense rs rn