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o tAPPLICATION AND <br />PLUMBING PERMIT <br />(TYPEWRITE OR PRINT IN INK) <br />CITY OF SANTA ANA <br />206 W. 4th Street <br />667-273€WAPPLICANT FILL IN AREA BELOW <br />(Dg-ozo <br />ool, <br />m(t <br />u) <br />u <br />r <br />\.N <br />Residential Dlndustrial DCommercial NO.EACH TOTALJOA <br />7 o2,U <br />FIXTURES,#rorue <br />kerz -DrD each plumbing fixture/trap q 5.00 4s- <br />Dental Unit or Medical Gases 10.00'o''5 Xl;> J.r,*Jt*,,t? tt )2"C-.,rr!&fi_a STATE/ZIP <br />Ourar.lulk.r Oadralbo <br />I hereby sttrrm thal I sm exmpl lrom tlE Cotraclo/s Lics* L8w tor the tollowing re8soo (S6. <br />7@l.5.BusinessndPror63ronsCod€ Anycityorcountywhachroquiresapormittocon3lruct. <br />alter. improve, d€moll8h. or roptar any 3ttucture. prior to it3 i&suence. al3o r6quira3 tho applicant <br />lor sch p€rmil to file a 3€n€d slatement lhat he is licsns€d pursulnl lo the piovisions ot the <br />Conlraclor's Liconso Lil (Chapts 9 (commencang wilh Soction 7m0) of Oiyision 3 o, lh€ <br />Busrnos and Prot6sioru @de) or thet he is ermpt thorarrom and the basis tor th€ dl€ged <br />exmplron Any violalion o, Sociion 7031.5 by any applicant ror I pormit subjocB tha appliclnt lo <br />a civil penalty ot not moro lhln ,ive hundr€d dollars (ts(I)) <br />E S*,ion 7@lA l. as owner ol lhe property. d myemployeswrth w6g6aar theirsol€compon- <br />3alion. wall do lhe wort. and the 3lr$ture is not inlsdod or otterod lor sale. <br />E S*t,on 70448 l, as ownd ol th€ propefly, am exclu3ively contracling with licsnsad <br />conlncloB to construcl lha proisct. <br />Dale Owner (Srg.) <br />s.00 <br />1st 100'+Conn. <br />Water Heater - Electric or Gas <br />Ea. Add'l Conn. <br />MISCELLANEOUS <br />Ea. Add'l 100' or Fraclion <br />'Temporary Gas Service <br />Private Sewage Disp. System <br />Repair or Beplace Gas Piping <br />GAS PIPING <br />Ea. Add'l Outlet <br />GAS SERVICE 1 to 4 Outlets <br />15.00 <br />30.00 <br />5.00 <br />5.00 <br />5.00 <br />100.00 <br />1.00 <br />5.00 <br />Conlreton Ur. Only <br />Water Piping Ea. 100'10.00 <br />b7*- ozaT <br />PHONE <br />Rain Water Piping (buried) Ea. 100'8.00 <br />Water Softner 4.00 <br />Alt. or Repair of Drainage - Vent Piping 10.00CITYSTATE/ZIP <br />6.00 <br />10.00 <br />8.00 <br />5.00 <br />Prol6srons Code, end my licens€ rs <br />L,cmsNo Stf|0r. 1",r"" <br />s.b <- l3 'Sfconrracto, <br />Orvtsron 3 ol lhe Eusings6 andof <br />and <br />I hereby sltirm lhat I am lacensed Rain System - Fer Drain <br />Deck Drain System - Per Drain <br />Lawn Sprinkler <br />lnd. Whste lnterceptor <br />Poql Traps <br />3.00 <br />Repair/Alt. Drainage or Vent 10.00 <br />Vacuum Breakers l-5 /5.00 <br />Over 5 1.00 <br />Backflow Device 2" or Less /5.00 <br />Over 2"10.00 <br />llodc. To A0dbrl: <br />ll alts makrng thrs C6lricateolEremptron, you should become sub,trl tolhe Wqke/s Comgen- <br />provi3ions ot lhe Lsbor Code. you must lorthwith comply wih such prolrisions or thi3 <br />shsll b€ d€6m€d raoked <br />Erparrfion <br />This p€rmit shal, orprre by limrlation and become null and void il the work aulhqized by this <br />i3 nol @mmencod wilhin lSOdays trom the dale ot this p€rmit d irworl authorizod by lhis <br />is susp€ndod or abandoned rt any timo atld lho work is commnc€d tor a psriod ol 180 <br />A new ptrmit shall be obtsined tirst before such work can be rocommencod. <br />Atflc.nl'. O.d...d6 <br />I certity thet I have rud lhis spplicslion and state thst the rbovo <br />comply with sll city ordrnancG and stste l8m relating to <br />orr.5:15-fr1 <br />Dclfdlon <br />12f Veriliod By <br />Applrcant or Agent <br />Date Applicanr (si9.) <br />copy is liled with the <br />ot consent lo <br />I cerlity lhal rn lho perlormancso, the <br />pe.son rn any menne, I 6 to <br />Californra <br />and heieby <br />I 8916 lo <br />I heroby allirm that I hava_ <br />ponsalion lnsurance. <br />e cartiricata ol Wortor's Com- <br />I inspeclion dopldmont. <br />Oale <br />Erpirgs <br />oan-C'21'Sl Appric8ot (sis.) <br />authorired r6praaonlalion ot this cily to Gntor <br />purpoG. <br />Water Service Ea. 100'10.00 <br />Subtotal <br />PERMIT <br />Receipt 7 -l Pc* <br />Fee (when applicable) <br />Violation Fee <br />Plan Check 650/0 ol subtotal <br />Plan Check (Adjustment) <br />lssuance Fee <br />TOTAL PERMIT FEE <br />(s0.00) <br />-Sa (minimum 2o.oo) <br />Date <br />10.00 <br />\ 0-''?!*i,y?"|flpy' ",,,(sig I <br />^vt-E *O-PEHMIT ISSUEO BY (Sig.) <br />ar.2-.]*"- p h\- lvt 7q 70 ,WO / /i,L <br />VALIDATION (OFFICE USE ONLY) <br />(ACCOUNT rrt-'l1a <br />Orstributron t lnspElor Copy 2 File Copy 3 Frnance Copy a Applacant Copy <br />cs-61 I <br />SEWER <br />I /5- <br />/5- <br />/ <br />/ <br />5l- <br />/o - <br />ttQF <br />sublect to Worker's