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,o oa, <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-Izo <br />oo <br />f, <br />mao <br />+ <br />JO8 <br />STATE/ZIPc (- <br />! lndustrial D Commercial NO.EACH TOTAL <br />o <br />FIXTURES <br />Dental Unit or Medical Gases <br />each plumbing fixture/trap 5.00 <br />10.00 <br />1st 100'+Conn. <br />Ea. Add'l Conn. <br />Ea. Add'l 100'or Fraction <br />Private Sanrage Disp. System <br />PIPING <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />GAS SERVICE 1 to 4 Oullets 5.00 5- <br />1.00 <br />5.00 <br />Ea. Add'l Outlet <br />Repair or Replace Gas Piping <br />Ortrr-arld.t E .lbn <br />I hereby artarm thal I am erempt lrom the &ntrrclor's Lrcens Law lor lhs lolbwing reason (Soc <br />7031 5. Busins and Prol6sions Code. Any ciiy or counly wiich requires I pelmit to construct, <br />alter. improvc. demolEh, d repair any structure, prior lo its isuance, also requitgs th€ appliclnl <br />,o, such permit to lils e signed statemenl thrt he i3 licenssd pu6uanl lo tho provisions ot tho <br />Contraclor's Licas Lil (Chspter 9 (commencrng with Setion 7@0) ol Oivision 3 ol th€ <br />Busanoss and Prote$aon3 code) or that he is exempl therelrom 8nd the basis lor the 8lleg€d <br />exomption Any violalim ol Selion 7031.5 by rny applicant ,or a p€rmit subiects lhe applicent lo <br />I civil p€nally ol nol morc than rive hundrad (bll8c (sgD)l <br />E S*ti- ZOgl l. 8s ownd o, the properly. or myemploy€€s wilh wag€8 sstheirsolscompsn- <br />ialron. will do the worl(. snd lha slruclura i3 not inlgndod q olls€d tor sle. <br />E S*tion 70448 l, as owB ol the properly. am exclcively cmlracling with licensad <br />cont6clo6 to conrtrucl lhe proi*i. <br />Oale Owner (Srg ) <br />Conlr*bn t r. Orly <br />CONTRACTOF I t a ).,(-C1.1 -o?o <br />PHONE <br />dooheSs-/Ara t ^- I-'' /'< L/ )3* fc.s rtvJ Alt. or Repair ol Drainage - Vent Piping <br />100.00 <br />/o - <br />10.00 <br />/ <br />Receipt No.Pc# <br />Temporary Gas Service <br />Water Service Ea. 100 <br />MISCELLANEOUS <br />Over 2" <br />Water Heater - Electric or Gas <br />Backllow Device 2" or Less <br />Water Piping Ea. 100' <br />Orcr5 <br />Rain Water Piping (buried) Ea. 100' <br />Vacuum Breakers 1-5 <br />Water Softner <br />Repair/Alt. Drainage or Vent <br />Lawn Sprinkler <br />Rain System - Per Drain <br />lnd. Waste lnterceptor <br />Pool Traps <br />Deck Drain - Per Drain <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 />8.00 <br />s.00 <br />Subtotal <br />Penalty Fee (when applicable) <br />Violation Fee <br />Plan Check 65"/o of subtotal <br />Plan Check (Adiustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />DATE <br />(s0.00) <br />Date <br />(minimum 20.00) <br />(minimum <br />PERMIT <br />L*i E(s, L ^?c <br />CITY STATE/ZIP <br />QA33 o <br />I hergby artirm that I am licans€d under the provi3ions ot Chspts 9. Oivisaon 3oltho Busino3send <br />on -5-19'4 Cont.actor (Srg. <br />in tull torce snd alltrtProlssions <br />Lrcense No <br />'glEi"*"" <br />ilolb. fo ADDllcrl: <br />ll alter makrng lhrs Cenricate of Exemptron, you should become sublel lo lhe Worker's Compen- <br />satron provrsrons ot lhe Labor Code, you must lo.lhwrlh comply wtth such p,ovrsons or lhrs <br />permrl shall be demed revoked <br />ar <br />*{*^n*tbn oclr.tlon <br />Date Applicant (Sig.) <br />to slt-insuro, or a ertitieta ot Worter's Com- <br />ircp€clion departmnt <br />pe.mit is issuod, I shall nol amploy0ny <br />I h€rsby allirm that I have a erliriete ol <br />I cenrty lhst In ths portormsnceorthe <br />poBon in any mnmr so s to <br />Calrlornra <br />oa"S'-15'-Sl Appticant (s,s ) <br />to the Workers Comoensalron Laws olal C. Cre {(rar <br />pensation lnsurance Certrfied @py rs <br />?:;,, 7/f,1 vs,,rcd By <br />Er,ilor <br />Thb permit 3h8ll oxpiro by limitllion 8nd becoma null and void it tho wort luthsizsd by thiE <br />pohil is nol commnced within lS0days trom lhcdlto ot this pormit tr ilsort lulhorizod by lhb <br />lErmil is sBpgnd€d or abandon€d d any tim atlor tha wort i3 cmmncsd tot r poriod ol !E0 <br />dayB. A nil pormit 3hsll ba oblainod liBt b€tofg such wort en ba rocommn€d. <br />I certity lhet I hevs roed lhrs applicstion end sl8to that th€ above <br />o"".s-ts-n?Applicanr of Agont (sig.) <br />end heraby <br />I aor& to <br />comply with ell cily ordrmncB and stat€ <br />luthonzod rcprantslion ol thh cily lo onttr <br />purpos. <br />-r\-LfB.'A'"9|S" 54Ab3,,,,,o PERMIT ISSUEO aY (Sig )atL**P *'?L /47?70 tffigq / Ptl- <br />vALroATroN (oFFrCE USE ONLY) <br />(ACCOUNT r1r-412) <br />Oislributron I lnspector Copy 2. File Copy 3. Fanance Copy il Applicant Copy <br />cs-6t r <br />/- <br />SEWER <br />U/LIZ-a <br />I <br />/ <br />f <br />-:=-- <br />7f- <br />8* <br />o