08060092 CITY OF CUPERTINO t «a�t '�* �`
BUILDING DIVISION' 'a PERMIT p CO,NTR`ACTOR,I�NFURMATION�
BL4MIflRE�YRNE AVE REZA RAFII 08060
u1092
OWNER'S NAME: PERMIT ISSUE DATE
RE'ZA RAFII 10484 BYRNE AVE 06/11/2008
NE: SANITARY NO. CONTROL NO.
ARCHIrEC'DENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
X00 LICENSED CONTRACTOR'S DECLARATION Ib Description
U F I humby aft,.that 1 ulis
n iued under Pmviumbs ommOescrl
f Chapter 9(ca
eneing p
`j with Section 7C00)ofoivieion 3 of Ne Sours,and Nefosa enceae.mW my Ear is TEMP POWER POLE
nR infullfomemWefrntt
j z Licenm Clue Lk.a
a„ Dau Comrmmr
n ARCHDECTS DECLARATION
1 understand my plans shall be used ss Public records
3iU
h no I Licensed Professional
5 OWNER-BUILDER DECLARATION
�c c 1 hereby.(sect Not 11. exempt from the ContracfeemomtCo e;Any c Law co tW
4 p O following mssan. etch t ](omme Business and Pro(cstiuv Code;Any city s county
e$�i which rtquis u a permit ro comment,the alar,micron,for such
demolish,t or e a sig any doconcre
'II<
prior to its issuance.also,rtquims the applicant for such p.rtnil to file aaigmd summcm
mm
thin heisliccnudpurmenttothe provisions ofuse Convect«i LicenseLaw(Chapter 9 Sq.Ft. FloorArea Valuation
yF (commencing with Section]0DO)of Division Sof the Business and Profession Code)or $500
i Net he is exempt therefrom and Om bar+,for the alleged exemption.Any violation of
Section 7031.5 by any applicant f«a permit subjects the applicant to a civil penalty ofNumber Occu ane T e
a.,more Nae fife hundred dollars(SM 3 5 714 013 . P Y YP
❑I.u aw«r of me prvperty,«my ermploycea with wage u Mev role campensstim,
will do the wot and ma momore is not Nodded or offered forsae,(Sm.7014,Busidem
and Profuuans code:The Comsm,aasmo rs Llaw does rot apply m are owner of Required Inspections
propectywho WiIN«impro es Nerton.and who deassuch worlahimuJf«Nmagh his
awo emPlayecs.PmWded Wt s«h improemenu art mtinseMe4«oRe,M(«sale I,
underWildh L cost ofemeru dml,t within arc yearw wmple for tlm
under will wiB lose tiro burden of proving Nat W did not dub«improve f«purpose of
s//ale.).
66.u masa of the property.w uclusivaly contracting with Bayed mnuaerms to
conitme,me Mjm(Sec.7W4,Bu mina and Professions Codm)rte Contractors U, .
cove taw does not apply on an owner of property who Wilds ar improvea Merton.and.
who contracts for such Pro ccut with a conussms(s)licensed pursuant in area Convenors
Licence law.
❑lamuemp"'undersm ,B&PCF tit
Ower 1 r A. I1C ,^ Dale (I
W R�SKER'S COMPENSATION DEC RATION VVV
1 Wmby affl m uM r penalty of perjuryem of me fallowing decluatians:
1 hew ono will msnuin•ction 37M.1
Coverar Com.to, f«Wod<r1 of on,
cation,r provided for by Section 3]00 of me Labor Code.far Ne peRormams of me
w0rlr for which this permit is issued.
0 1 bars and will maintain Workers Compensation Insurance,u acquired by Stiction
J]DO of the labor Cale,(or the performance of me work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cas,ier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisscerl.n reed net W completed if the permit is f«omhundred clothes($100)
orhss)
1 certify mat in the pmrsmama of me pork for whit is permit is issued 1 ilsll no,
ampaymypersoninanyrd r e• o ro h b to the Workers'compensation
Laws of Cali is Dau
Applicant /71 6 r
NOTICE T A ADtT:If.Wkr mikinj this Certifies of Etc option,you should
become subject m me Worker's compew0on provisions of the Labourde.coyou mass
.JO f.rthwith comply with such provfsans«Nis primit aball be deemed revoked.
z't;! CONSTRUCTION LENDING AGENCY
[-+ I barely affirm dot mem it...retreaded kndingagcncy for the performance of
C> Ne wort to,which this permit Is in.ed(sec.ver,Civ.C.)
aA Lenders Nam. .
z lenders Addaea
U Q 1 certify Nat 1 have read this application W amm Nat the above information Is
g4 F comttL I aLme the comply with sticky and must,ordinances and all laws relating m
O U building construction,and hereby m Boum mpretenutiset of this city he cat«upon the
4 aWvamcnudgir property for caposoon purposes _
F (We)agree to ase,indemnify and keep harmless Ne City of Cupertino against
ry Z incoitimcence,of the
es pe ape which may in any way attmc agunstsuo City
U z in consequence of Ne grantin of Nis permit
r APPLICANT UNpFRST fD5 AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREPULAT1d
Shgap7ccanuConvxtor Re-COOTS
tu
HAZARDOUS MATERIALS DISCLOSURE Data Type of Roof
Will the applicant or future building oceupantstom m handle haysdaus material
u deEncd by the Column..Municipal Cod..Chapter 9.12...it the Heath and Safety
Cale,Schon 25532()7
0Yaygtly. All roofs shall be inspected prior to any roofing material being installed.
wn th.a homt.r rumrc Wndid eau.rat axe If a roof is installed without first obtaining an P ins ection,I agree to remove
Pp d p cyvipmentar which
Duan`iard.w air ccouminmu u dc0md by tis Bay Ansa Air Quality
...anegemcm all new materials for inspection.
Dyes Nu
II 1 hale mal Ne hvadousm.urvum9u'vemmu mderCWpmr695 of me Califier.
nu Hahb&Safctycodc,S=u..505,25533uu125534.lunkwndthmifNe Wilding
ices roteunen0 �ma am Wtit u my raperulMlitY m mufy N.decorum,of do
requircmc h W roes prior m issuaRc of.Cuufiam of Oc
Signature of Applicant Date
Owner ifalftTArsill as All roof coverings to be Class'%¢•'or better
CITY OF CUPERTINO
• 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . .. 35714013 . 00
DATE ISSUED. . . . . . . : 06/11/2008
RECEIPT #. . . . . . . . . : BS000005087
REFERENCE ID # . . . : 08060092
SITE ADDRESS . . . . . : 10484 BYRNE AVE
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . I . . . . . .. REZA RAFII
ADDRESS . . . . . . . . . . : 10484 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : REZZA RAFII
CONTRACTOR . . . . . . . : LIC # *OWNER*
COMPANY . . . . . . . . . . : REZA RAFII
ADDRESS . . . . . . . . . . : 10484 BYRNE AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE . . . . . . . . :
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
1BSEISMICR VALUATION 500 . 00 0 . 50 0 . 00 0 . 50 0 . 00
1ELCPLNCK HOURS 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
1ERT<200 UNITS 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
--------- ---------- ---------- ----------
TOTAL PERMIT 204...46 0 . 00 204 .46 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE .NUMBER
----------------- --------------- --------------------
CREDIT CARD 204 . 46 VISA
-------------
TOTAL RECEIPT 204 . 46
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
402 TEMPORARY POWER
1
0�0 (PD0ga
CITY OF CUPERTINO
TEMP POWER
• CUPEI�TINO PERMIT APPLICATION FORM
APN # Date: 6
Building Address:
r-Aa A Qso/�
Owner's Name: Phone #:
R ( (40�
Contractor: Phone
( o�I 472- ? q l
Fax #: p O O O
Contact: Phone #:
Contractor License #: 3 [{ Z
Cupertino Business License #:
Job Description:
• 1 r�Ot�—�sZ!`
Residential Commercial ❑
Valuation (cost of project): Q/ (% 0 O
Quantity Fee ID Fee Description Fee Group Permit Type
1 ERT>1 K Res. Temp Power>I K E 1 REAP14
Amps
i 1 ERT<200 Res. Temp Power <200 E
Amps
-FE R 0001 K Res. Temp Power 200-1 K E
Amps
I EPERMITFE Electric Permit Issuance E
IELCPLNCK Electric Plan Check E
• 1BSEISMI-CR Seismic Residential B
i
ITRAVDOC Travel & Documentation B
Fee
as
CITY OF CUPERTINO
TEMP POWER
OF
CUPERTINO PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group Permit Type
1BSEISMICO Seismic Commercial B 10EAP14
IECT<200 Commercial Temp Power E
<200 Amps
IECT>1K Commercial Temp Power E
>lK Amps
IECT2001K Commercial Temp Power E
100-IKAm s
1TRAVDOC Travel & Documentation B
Fee
1BUSLIC Business License B
n Community Development
30 Torre Avenue
A
✓ CuOpertino CA 95014
Y Telephone(408)777-3228
CITY Of Fax(408)777-3333
WUPEI�TINO
Building De artment
JOB ADDRESS: cupT"y� PERMIT #
I o 4 !w1 0-- A U2 J0(4-
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR: ���} f}�(! FAX p p 7 00
I am not using any subcontractors: D 67
Signature bate
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
•
46er&Con�t�ractor Signature E54