HomeMy WebLinkAbout285008/14/2013 wED 14:16 FAA
74
"'""f PLUMBING PERMIT APPLICATION
City of Hermosa Beach - Community Development Department ac,
Ii001/001
Each Plumbing Fixture, Trap or Set of Fixtures
on One Trap (Including Water, Drain Piping
and Backflow Protection)
,1'.iBuilding Sewbr
'2. Trailer Park Sewer
3. Rainwater System - Per Drain (Inside
Building)
4\ Water HeaterNent
Gas Piping Outlets (Enter No. of Outlets):
a) 1-5 Outlets. Total Fee
b) Over 5 (Per Outlet
Industrial Waste Pretreatment
1. Interceptor, Including Trap and Vent
2. Undersink Grease Trap
Each Installation, Alteration or Repair of Water
System (Piping Equipment or Repipe).
Total Re -pipe = Main + No. of Fixtures
$22
QTY
35
AMOUNT JOB ADDRESS:
770, cc x.8'50 tI-0e57e 116,
Each Repair or Alteration of Drainage or Vent
Piping •
$ 43
$ 22
$ 22
$ 33,Total
$ 7.. Each
4
$ 33
$ 11
r q U JOB DESCRIPTION:
rue -ti ffore- / +
22,e1
3r
$ 11
Each Lawn Sprinkler System on any One
Meter (Including Backflow Protection Devices)
Atmospheric-Ty9 Vacuum Breakers (Not
Included in Abovb Item)
a 1-5, Total Fee
b. Over 5 (Per Breaker)
$ 22
$ 22 Total
$ 7 Each
Each Backflow Protective Device (Other Than
Atmospheric -Type Vacuum Breakers):
a. 2 Inches and Smaller
b. Over 2 Inches
$ 22 Each
$ 22 Each
PROPERTY OWNER(S) NAME:
Tom. 4
l // B, Ca -n-4;7
ADDRESS:
329 e,N,
CIN,' STATE, ZIP:
840.44-6-9t6,254/
PHONE:
3/0-, 79 7-- 6 5 CJ
PLUMBING CONTRACTOR:
EMAIL ADDRESS:
ADDRESS
//(o 1 s, P,4 a-ert•
CITY, STATE, ZIP:
1fd6 6P 'c) z 56
PHONE:
3f6 -- 0 aci
1. Fire Sprinkler Piping System
a. 1-10 Heads
b. 11-25 Heads
o. 26-50 Heads
d. 51-100 Heads
e. 101-200 Heads
f. 201- 300 Heads
g. 301-500 Heads
h. 501-1000 Heads
i_ 1001 or More Heads
2. Sprinkler Riser Pipe
Miscellaneous
$ 22 Plus
$ 37
$ 61
LLB
.$133
184
3234
$306
$459
$660
$ 11 Each
$ 33
Supplemental Permit Fee
Issuance Fee
TOTAL FEE
$ 17
$60
BUSINESS LICENSE NO.:
OOL'Z SSQC
STATE LICENSE NO.:
34/ z9it
TYytOF,B I :
NO. OF STORIES:.STORIES:.
2 w'"`°`'�'�'
NO. OF Mr ERS: �,/
NO. OF FAMILIES:
DATE ISSUED:
tv 0, Oa ISSUED BY:
? ' d6 PERMIT NO.:
/y
fiLf- aaa q3
*PLEASE CONTACT THE PUBLIC WORKS DEPARTMENT AT (310) f8 0214 IF
WORK IS QQ111G'To BE DONE IN THE PUBLIC RIGHT OF WAY (S,112.< OR REET .
I hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws
and ordinances governing this type of work will be complied with whether specified herein or not. No person shall be allowed to
perform work under this permit In violation of the labor code of the State of California. I further state that I am properly licensed
as required by Section 7031.5 of the State Business and Professional Code (or claim exemption under Section 7044).
2440/
Signature of Contractor- - Signature of Owner (If OwnerlBullder)
F:1395/cd/forms-hand outs/application/plumbing 9-1-11 Revised 10/3111