HomeMy WebLinkAbout1600 (3)PLUMBING PERMIT APPLICATION
City of Hermosa Beach - Community Development Department ti -027, v
Each Plumbing Fixture, Trap or Set of
Fixtures on One Trap (Including Water, Drain
Piping and Backflow Protection)
$ 22
QTY
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AMOUNT
JOB ADDRESS: 1/
/600 f'/ �t.d2� ,4V
JOB DESCRIPTION:
{ZEW1Oci-C_ O(et riia2ek MCS
�acb jShaw �. `Sf'4 (< n
li/J- Carl IX 1&/b4,
1. Building Sewer
2. Trailer Park Sewer
3. Rainwater System - Per Drain (Inside
Building)
4. Water HeaterNent
5. Gas Piping Outlets (Enter No. of Outlets):
a) 1-5 Outlets, Total Fee
b) Over 5 (Per Outlet)
$ 43
$ 43
$ 22
$ 22
PROPERTY OWNER(S) NAME:
{ten i -e.-• Z1'1S m e. /,STI
$ 33 Total
$ 7 Each
ADDRESS: -dad
gad
Industrial Waste Pretreatment
1. Interceptor, Including Trap and Vent
2. Undersink Grease Trap
L54
CITY, STATE, ZIP:
%�eXln-ejdL-, Ca 9Oa 5
$ 33
Each Installation, Alteration or Repair of
Water System (Piping Equipment or Repipe).
Total Re -pipe = Main + No. of Fixtures
$ 11
PHONE:
3/61 _2"a(2_c)977 V
Each Repair or Alteration of Drainage or Vent
Piping
$ 11
PLUMBING CONTRACTOR:
6ekhocritb , /etsc, P(uePt
Each Lawn Sprinkler System on any One
Meter (Including Backflow Protection Devices)
$ 22
EMAIL ADDRESS: ,, t
mq�v2,s� E �clo�/�4tJe�
Atmospheric -Type Vacuum Breakers (Not
Included in Above Item)
a. 1-5, Total Fee
b. Over 5 (Per Breaker)
$ 22 Total
ADDRESS
3,R 41/4ti .e(
$ 7 Each
Each Backflow Protective Device (Other Than
Atmospheric -Type Vacuum Breakers):
a. 2 Inches and Smaller
b. Over 2 Inches
$ 22 Each
CITY, STATE, ZIP:
La, 40?o(oS Cf 90vic--
PHONE:
3/o.cyisYid �
$ 22 Each
1. Fire Sprinkler Piping System
a. 1-10 Heads
b. 11-25 Heads
c. 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
$ 22 Plus
$ 3
BUSINES LICENSE NO.:
3 /2P c 9
$ 611
$ 86
STATE LICENSE NO.:
$133
$184
TYPE OF BUILDING::" ,,
C4/1 u rJ
$234
$306
NO. OF STORIES: C!
$459
$660
NO. OF METERS: /
$ 11 Each
Miscellaneous
$ 33
NO. OF FAMILIES:
(.(vlk.it.ockb-7
Supplemental Permit Fee
$ 17
DATE ISSUED: gpionee-ci-
t-,
Issuance Fee
$ 59
TOTAL FEE
ISSUED BY:
..•• a IS ,.... SM. ...— •••••.•.............--•-- --- - ------ - - - - - - - -- -
PERMIT NO.:
'QM -60141
WORK IS GOING TO BE DONE IN THE PUBLIC RIGHT OF WAY (SIDEWALK OR STREET).
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 goveming 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 Califomia. 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).
Signature of Contractor
Signature of Owner (If Owner/Builder)
F:b95/cd/forms-handouts/application/plumbing 9-1-11 Revised 10/3/11