12264 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
ADDRESS APPLICATION & PERMIT 12264
ADDRESS
�1 v BUILDING -ELECTRICAL-PLUMBING-MECHANICAL
U ERS �"� PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
�^ E
RA TOR
NAMEUTLETS-SWITCHES-RECEP 10.00/1.00
LC,No. S LIGHTING FIXTURES 10.00/1.00
CONTRA r A.
ADDRESS APPLIANCES-RESIDENTIAL 4.00
L2- Ne y
V PNONE p PANELS 1D.DD DATE OF APPLICATION
ORRCwiEC PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
- uc.NO. SIGNS TRANS. 3.00
ADDRESS ENc. SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP TEMP.METER OR POLE INS. 20.00
ADDRESS MOTORS SEE FEE SCH. �J J
SERVICE CHANGE 20.00 //
woo LICENSED CONTRACTORS DECLARATION iii///
a U w I hereby affirm that I atm licensed under provisions of Chapter 9 ISSUANCE DATE
v, a N se
(commencing with Section 7000)of Division 3 of the Business and B G. ELECT. PLG. MECH.
H w z Professions Cojly;a` my license is in full for
pfi elf
z O nL ❑ ❑ ❑
n - icense Class Ja c.Number �Y
w1-w Oate Contractor -
a >: BUILDING PERMIT
¢ a,w OWNER.BUILDER DECLARATION INFORMATION
X ;LL N 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
H u o j Law for the following reason(See.7031.5,Businessand Professions PERMIT ISSUANCE 10.001VALUATION S/FT,
Code:Any city or county which reyuiresa permit to construct,alteq
Q Q Q Improve,demolish,or repair any structure,prior to Its issuance,also ELEC.CONTE, LIC.NO. EL EC. _
n wDLL requires the applicant for such permit to file a signed statement that TOTAL PERM TO
m he Is licensed pursuant to the provisions of the ConlraJta!s License
H z aLaw(Chapter 9(commencing with Section 7000)of Division 3 ofthe
E i o Business and Professions Code)or that he isexempt therefrom and QTY. PLUMBING PERMIT FEE
¢r m the basis for the alleged exemption Any violation of Section 7031.5 STORIhS _ TYPE CONSTR.
n F_ � by any applicant For a permit subjects the applicant to a civil penalty
of not more than five hundred dollars(S500).): ALTER-DRAIN&VENT-WATER (EA.) 5.00
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
properly who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 SO,FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
ments are not intended or offered forsale.IL however,the building GAS-EA.SYSTEM-I INC.4 OUTLETS 6.00
or improvement is sold within one year of completion,the owner-
builder will have lite burden of proving that he did not build or im- GAS-EA.SYSTEM-OVER 4(EA.) 2.00 BUILDING USE
prove for purpose of sale.). INDUSTRIALWASTE IN ER. 30.00 I❑ ❑N 1PEI:1O❑'
C) 1,as owner of the property,am exclusively contracting with
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractorts)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/10.00 TRACT NO. PARCEL NO.
reason❑ l am exempt under Sec...B.&P.C,for this WATER HEATER W/VENT 6.00
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKE:RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
1 hereby affirm that I have a certificate of consent t,'elfin sure,
or a certificate of Workers'Compensation Insurance•or a certified ZONING ENG.SITE NO.
copy thereof(Sec.3800,Lab.CJ.
Policy No. Company
O ❑ Certified Copy is her by furnished FIFE SPRINK ENERGYT I4
Z Z Certified copy�rs i •d with the city inspec Uun division.
Alicant ......'� -f MISC- REFER TO ORD. Y ❑ N❑ Y ❑ N❑
~ rn V PERMIT ISSUANCE 10,00
LU COMPENSATION
EXEMPTION FROM WORKfiRS' FLOOD ZONE A.LU.C.
W COMPENSATION INSURANCEPLG.CONTE, LIC.NO. PLG.
d Q (This section need not be completed if the permit is for one TOTAL Y❑ N❑ Y❑ N❑
Z hundred dollars IS 100)or less.)
L) O 1 certify that in the performance of the work for which this per- OTV MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,1 shall not employ any person in any manner so as to
O W become subject to the Workers'Compensation Laws of CABornia.
y
Date-Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
>- W NOTICE,TO APPLICANT': If,after making this Certificate of lix-
2 emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10MC.F.M.) 4.00 FEE
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER 10,000C.EM.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.L HEATING UNIT(TO 100,000 B.T.U.) 8.00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)9.50 ELECTRIC
1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING
ordinances :md State laws relating to building construction, and BOILER-COMPI3 H.P.or 100,000 B.T.U.) 6.00
hereby authorize representatives of this city to enter upon the BOILER-COMP lover 100,000 BTU)SEE FEE SCM.
above-mentioned property for inspection purposes. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE CONST.TAX
may in any way rue against Said City in consequence of the 10.00
grantingofllhi erh tt MECH.CONT. LIC.NO. MECH.
z� TOTAL TOTAL
Signature of plocan[ onl c[or ate
OFFICE COPY