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\ <br />o aAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OB PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-2736 <br />APPLICANT FILL IN AREA BELOW <br />tDg-Izo <br />oo <br />f,maa <br />>G&Ldsntial Elndustrial DCommercial NO.EACH rorfr- <br />Y-rh*v;,h-dft-Pt 6NE <br />54 z -o//a"ry;TZ -/.,',u,,-)zZ""/?ooL- )rr-r----STATE/ZIPq2LzL <br />24) <br />or Gas <br />FIXTURES <br />Ea. Add'l Outlet <br />each plumbing fixture/trap <br />GAS SERVICE 1 to 4 Outlets <br />Dental Unit or Medical Gases <br />SEWER <br />1st 100'+Conn. <br />Ea. Add'l Conn. <br />Ea. Add'l 100' or Fraction <br />Private Disp. <br />PIPING <br />5.00 <br />10.00 <br />15.00 <br />30.00 <br />s.00 <br />5.00 <br />5.00 <br />5.00 <br />1.00 <br />Temporary Gas Service 100.00 <br />MISCELLANEOUS <br />Ourt-ldl(bt O.d.tfbn <br />I hereby allirm that I am exmpl trom lha Contracto/s Lic€ns Law lor the lollowing r6Bm (Se <br />761 5. Eusrne$ and Pror6aons Codg Any city or county which roquira ! p€rmil to con3lrrcl. <br />all6r. imp.ove. demolish. or .opaar any 3lructur6, prio. to als Bsuanca, ds roquirB lhe spplicant <br />lor such p€rmat to ,il6 r sqnod llalom6nt lhal he as lic€nsod puGuanl lo the prcvisions ol lha <br />Conlractor's Lacan3s Lsr (Chapler 9 (comm€ncing with Soction 7@0) ol OivBion 3 ot lhe <br />8usano$ 8nd Prot€asiofis Code) or thrt hs i3 erompt lhererrom 8nd lhe bais tor lhe 8ll€9€d <br />exgmptaon. Any vDlalion ol Soction N)3 1.5 by rny epplic8nl tor a permil subiocts the applactnl lo <br />a civil pemlty o, nol mor6 than tiva hundrsd do1186 (35m): <br />E Sclbn 7Or4.lA l. 83 ownor ol tho property. or my amplolEs wath wages !3lheir 3olo compan- <br />salion, will do lh€ mrk, snd tho strrclure is nol inlmdod s ofterod l,or Salo <br />E S*tio, 7(N48 l. ss owner ol lha propony. am cxclusivoly contr*ting r,rn iir.rd <br />conlrecloB to conSlruct thg proigct. <br />Oate Owner {Sig ) <br />5.00 <br />Contrrclo[ l,rar Only A3 '10.00 43o'o"'i)'12 L / <br />Water Heater - Electric or Gas <br />Water Piping Ea. 100' <br />Rain lrtJat€r Piping (buried) Ea. 100'2 2.5a It 8.00 <br />Water Softner 4.00\Azr-Z- %zJ- 47v4p/>2/ /AOORESS <br />Alt. or Repair ol Drainage - Vent Piping 10.00"'%L-D-' o.G- -%tzoa,{-t <br />STATE/ZIP <br />?2 b47 Lawn Sprinkler 6.00 <br />Rain System - Per Drain 10.00 <br />lnd. Waste lnterceptor 8.00 <br />Pool Traps 5.00 <br />undor the provisions ol Chapter 9, Oivision 3ollhe Busin6sand <br />eOete <br />City // <br />I he.eby allirm thal I 8m <br />Code, and B an lull 8nd et *t <br />3.00Deck Drain System - Per Drain <br />Repair/Alt. Drainage or Vent 10.00 <br />Vacuum Beakers 1-5 5.00 <br />Owr5 'r .00 <br />trolt.rr CG.tpilalbn Oaarrdon <br />I hsrcby Itlirm that I herc e ertiricrte ot @n3€nt to $lt-insure. or a cerlitiete ol Wo,td's Com- <br />p€ilon in any manmr so a lo becom subiocl lo lh€ Worto/s Componsalion Law3 ol <br />Calilomo <br />,aolb. To Afrfcrrl: <br />It afier making lhis CgtiricstaotEramption. you should b€@m6subiet to thaWo.ta/sCompefr <br />salion provBions ot lhc L8bor Cod€. you must loilhwrlh comply with sch provisions d this <br />permrl shall ba demsd ra.olcd <br />wilh the departmenl. <br />I certify that in the p€rldmarceof thispermit is bsad. l shall rctemployany <br />Dste <br />- <br />Appliont (sig.) <br />** 0 -S-K? <br />^ppriclnr <br />(sre. <br />pensaton lnsurante furfiod @py E filsd <br />*i1"" cl-tt - veri,i6d By (s,e ) <br />Backllow Device 2" or Less <br />Water Service Ea. 100' <br />Over 2" <br />5.00 <br />10.00 <br />10.00 <br />Subtotal <br />lssuance Fee <br />Fenatty tue (when applicable) <br />Violation Fee <br />Plan Check 657" of subtotal <br />Pc#Receipt No. <br />Plan Check <br />(s0.oo) <br />Date <br />(minimum 20.00) <br />10.00 <br />7. <br />EiDartldt <br />This permicsh.ll expira by limilltion and bocomo null andvoid i, t,io rorl authdi:od by this <br />permil is not commncod within lEoday3 rom thodrlo o, lhis permit d ilrcrtaulhorizod by this <br />p€rmit as Suspended d rbendoned et any lim 8lltr ths uort is cmmncsd lor I poriod ol 180 <br />days. A n* pamit 3h8ll be obtainod tiBl b€lss Such worl cln bo racommonc€d. <br />ArDlonl'.E don <br />I cenity thal I hava rEd thB applicatim end stele lhrnh€ lbove <br />euthorized repr@ntation ol thas cily to 6nttr upon the <br />Oate :s- <br />to <br />Applicant or Agent <br />I a9r6 to <br />h6reby@m9ly wilh 8ll crly ordimncos and slato laws <br />(minimum $35.00) <br />NoI r839 <br />rOTAL PERMIT FEE <br />-8? <br />\l*-B!*i,ifr, iAh s */,,, o ",,.,n,PERMIT ISSUED BY (Sig.) <br />"/-ot0l3? <br />vALroATroN (oFFrcE usE oNLY) <br />(ACCOUNT r11-412) <br />L <br />Oistribution: 1. lnspeclor Copy 2. File Copy 3 <br />'.637.m cs-61 I <br />rl <br />7d <br />': <br />t