8141 APPLICANT TO FILL^IN'INFORMATION WITHIN REDLINES - USE BALL POINT PEN ONLY
13U ILD I NG P,ROJECT•I DENT[F[CATION PERMIT NUMBER
f�
8UHLONG - �. APPLICATION & PERMIT
ADDRESS /u/' WaGFt ll
I.14a neat , Valco Park BUILDING-ELECTRICAL-PLUMBING -MECHANICAL 81 t!�
OwNER'S -T^- PLAN CHECK VALIDATION
NAME OTY. ELECTRIC PERMIT FEE -
Glemby Internatioml
i
NDERACTons UTLETS-SWITCHES-RECEP 10.00/1.00
uc.No220078 LIGHTING FIXTURES 10.00/1.00
CONTHACTOH'S P.O. OyX 40069 PPLIANCES-RESIDENTIAL 4.00 '
ADDRESS
rvE PANELS 10.00 DATE OF APPLICATION
RCHRECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO,
O
OR
j ENGINEER -
I uc.NO, SIGNS TRANS. 3.00
i
ADDRESS ENG' SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
Zip EMP.METER OR POLE INS. 20.00
N Doli SSTs P.O. BOX 40069 MOTORS SEE FEE SCR. - 1
SAn FrFine-ise-in CA 94140
SERVICE CHANGE 20.00
wo o LICENSED CONTRACTORS DECLARATIONTEMP.POLE 30.00
a u u 1 hareby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
;t H z w (commencing with Section 7000)of Division 3 of the Business and
BLDG. ELECT. PLG. MECH.
H D i Professions Code d m license is in full force and effect. ❑ ❑ ❑
z o w - License Class Lia Number 97)13 7�
:
, . - 0 Date Contractor
a ee 2 -1BUILDING P RMIT
M o n u OWNER-BUILDER DECLARATION INFORMATION
wI hereby affirm tllat I am exempt from the Contractor's License MISC.- REFER TO ORD
u o¢ Law for the followingreason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 10.00 VALUATION 8/FT.
H _
Code:Anychy crcounty which requires a permit to construct,alter,
Qto¢o improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO., ELEC. '
D u, requires the applicant for such permit to file a signed statement that TOTAL PER IT j /I
a w re he is licensed pursuant to the provisions of the Contractor's License 'V//l�I
H z aLaw(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
¢ r 0 the basis fit the alleged exemption.Any violation of Section 7031.$ STORIES TYPE CONSTR.
w. by:my applicant for a permit subjects the applicant ton civil Penalty ALTER-DRAIN.& VENT-WATER (EA.) I
.1"W more than five hundred dollars($500).): F
❑ I,as owner of the Property,or my employees with wages as BACK FLOW PROTECT. DEVICE ace.caouP RES.UNITS
sole compensation,will do the work,aid [Ire structure is not
intended or offered for sale (Sec. 7044. Business and Professions DRAINS-FLOOR,ROOF,AREA,COND.
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 510a Sa FT.FLOOR AREA TOTAL ACREAGE
• meuelf re of intended
his own employees,provided that such improve-
himself a through
his oroffered for employeesalclLed that such
building GAS-EA.SYSTEM-11NC.40UTLETS 6.
or improvement is sold within one year of completion,lire owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.0 BUILDING DSE
builder will have the burden of proving that he did not build or M.
prove for purpose of sale.). INDUSTRIAL WASTE INTERRES IND CDN PB Omer
. 30
❑ I,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.
.f and Professions Code: the Contractor's License Law does not apply
J, to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS.-OVER 5 (EA.) 1,Q0 _
11 contracts forctor*shceneets Lwithucontmctorts)licensed pursuant to SEWER-SANITARY-STORM EA.200ft/10. TRACT NO. PARCEL NO.
the Contractor's License Law.
❑ I nn exempt under See. ,BAP.C.for this WATER HEATER W/VENT 6.
reason ,90
Owner Date WATER'SYSTEM 5.99 ACC.DATE ACC.FILE No.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.OR
I hereby affirm dict 1 have a certificate of consent lu Su1f-insure. ZONING ENG.SITE N0.
or a eerliflcnle of Workers'Compensation Insurance,or a ecnibed
copy thereooff f Sece.3800,Lab.C.).
0 I'olicl+'Y}i.1R l a l a�by furors ted. '
yf��1..-�c�TTllccuu 7 FIRE SPRINK ENERGY T 24
.z z ft Certified c Py s_f`led with the city inspection division.
O Applicant MISC.- REFER TO ORD. Y❑ N❑ v ❑ N❑
CC w CERTIFI TIi OP EXEMPTION FROSI WORK (ERS' PERMIT ISSUANCE iJQ1W ,p p FLOOD ZONE A.L.U.C.
LU .COMPENSATION INSURANC17 PLG.CONTR. LIC.NO. PLG. ❑ Y[:] N❑
0- Z (This action need not be completed if the Permit is for one Q P TOTAL /y/)6t 0 Y[:] N
hundred dollars IS 100)or less.)
f C) O 1 certify that in the performance of the work for which this per- QTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL 1- mit is issued,I shall not employ any person in any manner so as to
0 W become subject to the Workers'Compensation Laws of California.
a Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Fx-
F 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 FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.) 4.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the Ndorn once of the work for which this permit is issued IS". MICROFILM
3097,Civ.C.). HEATING UNIT (TO 100,000 B.T.U.) 8.00
Lender's Name HEATING UNIT(OVER 100,000 B.T.U.)9.50
LL-ndcr Address ELECTRIC
kI certify that I have read Ods application and stale that the above ,VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and county PLUMBING I
ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.o-100,000B.T.U.) 6.00
hereby authorize representatives of this city to em
cr upon the BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned pfoperty for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against liabilities,judgments, costs and oxpenses which PER IT ISSUANCE 10.00 CONST.TAX
may in any way accrue against mid City in consequence of the r.,,
gine)Ing (this'permit. MECH.CON F'- LIC.NO. MECH. ) /
� 2/28/85 _ ' " TOTAL TOTAL II'(,ly1l Jl/'
Signature of Applicant/Cmutractor�� Date '
„'INSPECTOR COPY '