05070128 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT 'CON
TaaRAeC€Ta�O,Myr Rf INF( IMATIO'°N °'
BUILDING ADDRESS: CONDITIONED AIR PERMITN0.05070128
21527
OWNER'S NAME: PERMIT I%"DATE
YORAM BENYAN 1701 LITTLE 05
NE: SANITARY NO, CONTROL NO.
(408) 291-2220
ARCHTfECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Z 0 0 0 0
30p LICENSED CONTRACTOR'S DECLARATION Job Description
I hmcby sf1Um Net I Am licensed under provisions of Chapter 9(commencing o
with Section 70flay of Division 7 of Ne Buse.annd Pmfessiom Co ld.and my license is
^ IO mufamcamdAffem e-) REPLACE FURNACE AND. ADD A/C
$z_ License Class G'aO Idc.
9' Dam Comncmr
�- -AACHf1ECl'S DECLAR TION
1 raundm lansahal be used blic records
�6�ya.
403 LleCneCd n SSlonel
Oat I am exempt
from
DECLARATION
4<0 I hereby afOrm on 1 am exempt from Na Contractor's :My c Law for Ura
i
00 following moon.ISectin 703 dvocat Business and w,.de oli Code: *city or county
$ which requires issuance,permil re sines 4 altar,Mprosw,demmuh,m e a sig any o mum ']6 5 0
priorm RLLcensed 1150 rmantto the dm applicant far such permit m EICasignedChmmepl
< IwnmincingwitpmctanTWthe O)ofDielowofumcammamrwec.uonsCocmt9 Sq.Ft. Floor Area Valuation
(Co9 that he is
Section andtlUlvulafr o(timeged exemton.Any vi Code)or
- Nn h t,exempt Nemfam and tk buil far Ne alleged exemption.Any violation of
am than
I.s five any applicant for a permit pbjecu the.pplieant to,ei.n penodly of .r_ Occupancy Type
Tat mart Nm Ove hundtad icant f($SW).
❑1,As ownerof Nmpropesly,mmyemploycu with"Was Ne'u sole emnpenatim.
will do Newark.ande:The Cumister's Licenseanded clattered dataa set apply Ad N.Business
And property
wh ou Code:The.,doctor's Idanu law data mut apply ir t owner of
propertywho s,provided
sch Improvement,
andwho Am,Act
omplredthough his
awn employees,provided that such Improw:menu sa 1191 intended arortemA forsak.l(.
hawew.du Wilding ser den of pmmlishathe did aneyeti of Improve
fa,Ncawayf /
builder will have use burden of proving that he did nom build or Improv for purpose ser
plc.).
❑I.as Owner of the property,am exclusively contracting with liaised contactors to
contract the project(See.7014.Business and Professions Cade:)The CmsactoYs U.
sue law does Tat apply to an away of property who build.or improve therma.end,
who cannot,for such projects with aeonuxtor(s)llaosed pursuant to Na Contractor's
License law.
❑I em exempt under Sea. .B 6:P C fm this nose.
c Dau
WORKER'S COMPENSATION DECLARATION
I heaby affirm under parody of perjury ane of the following declaations:
❑I have And will maintain a CeNfmcom of Covent to self-Inane for Worker's Comp a.
puon,As provided for by Section 3700 of the labor Code,far the peformana of Into
wart for which this Parnell is issued.
❑1 hale and will maintain Worker's Campcwtion Insurance.As acquired by Section
3700 of the Labor Code,far the performance of Ne work for which this permit is issued.
My Wad_ee,Compensation Insurance carrier and Policy
numbcF am:
Cartier. ((9WPolicy No.:�^ � VG ON
FROM WOR S'
COMPENSATION INSURANCE
(This section need not W completed 1f the permit is foranehundred dollars(SIM)
or Iasi
I certify that I.the performance of the work for which this permit is issued.I shod nm
employ anypersan in any maser anti m became subject An the Woderf Compeau0on
Law.of California.Dam
Appimmt
NOTICE TO APPLICANT:If..fur making this CenifIcam of Exemption,you should
become subject m the Worker's Compensation pmvislons of NO Lobar Cade,you must
,J O forthwith comply with such po.09.ser this permit Mall W Actuates¢voted.
z'n CONSTRUCTION LENDING AGENCY
[-m Ihereby Man Nan Orem Is a construction leading agency fm the pantomime,of
E
the wad for which this permit Is issued(Sec.3097,Cih,C.)
GQ Larder's Neu ,
a z Lender's Address
U O I certify that 1 Mw tad this application and sum that the above Information is
D.F corrin 1 qac to comply with all city and county ordinanm and sum laws elating to
C V buildingoonswction,andherebyAuthorizeepresentative;ofthiscitytoAmeruponthe
til alave-mentioned property An Inspection purposes.
(We)agree to save,indemnify and kap harmlast the City of Cupcnino against
VI Ilebilidesjudimen0.eam and expenses which may in anyway ammo against said City
(„)7 Inconsequence ofthe granting of this permit. `�'J�'l /�
F7 APPLICANT UNDERSTANDS AND WIL CQQMMPLY WITH ALL NOWPOINT Issued by: Date / L —1
SOUR=ECU ONS. �T/J
fi/S!/off Re-roofs
�r S�L
Si{n a AppliandCon a Dam
HAZARDOUSrAAMIALS DISCLOSURE Type of Roof
Will the applicant or future building accupa,atom or barium huardous martial
as defined by the Cupertino Municipal Code.Chaptar 9.11,sand the Health and Safety
Code,Section 15331(.)7
❑Ya Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or loom building occupant new equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Cell hasaadnw aircnnmminsnss As defined by the Bay Am.Air Quality Maugement all new materials for inspection.
Dissict7
❑Yes 09pia
Illave mW Ac havardousmateriels requireman s under Chaptar6.93 ofthe C.lifoa
TialkmthkSAfclYCcdc,Sammm29305,13533"21334.1undcaund NulfNo Wilding
dna not curmnlly hove a tenant,Nat It Is my ruponsihility to notify dm oecupant of Ne
Mqulem whichmutWmetpdar luuana n Im.m ser Ocmpamy. Signature of Applicant Date
l� fo
Ow irhomcde em Dam
All roof coverings to be Class "B"or better
CITY OF CUPERTINO
2 of 3 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 4
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35623025.00
DATE ISSUED. . . . . . . : 07/21/2005
RECEIPT #. . . . . . . . . : 30458
REFERENCE ID # . . . : 05070128
SITE ADDRESS . . . . . : 21527 RAINBOW DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : YORAM BENYAN
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4816
RECEIVED FROM . . . . : CONDITIONED AIR ASOC
CONTRACTOR . . . . . . . : RICHARD READ LIC # 22334
COMPANY . . . . . . . . . . : CONDITIONED AIR
ADDRESS . . . . . . . . . . 1701 LITTLE ORCHARD ST
CITY/STATE/ZIP . . . : SAN JOSE, CA 95125
TELEPHONE . . . . . . . . : (408)291-2220
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 7,650.00 147.96 0.00 147.96 0.00
BREMAIRHAN NO.UNITS 1.00 10.26 0.00 10.26 0.00
BENERGY PERMIT FEE 147.96 71.02 0.00 71.02 0.00
BREMFURN NO UNIT 1.00 14.31 0.00 14 .31 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
BSEISMICRE VALUATION 8,000.00 0.80 0.00 0.80 0.00
EPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
MPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ __________ ----------
TOTAL PERMIT 359.46 0.00 359.46 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
301 ROUGH PLUMBING 303 ROUGH MECHANICAL
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
507 FINAL PLUMBING 508 FINAL MECHANICAL
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
OCF
Fax(408)777-3333
OUERINO
Building De artment
JOB ADDRESS: PERMIT#
IS Qbe i'rn0 CK1 1 0 S -O 7 0(2
OWNER'S NAME: n r IPHONE# Cyp (JQA:aS\ Cj
GENERAL CONTRACTOR j FAX#
I am not using any subcontractors: :7101 t05
Signa a Date
Please check applicable subcontractors and complete the followin ' ormation
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 Me
Sheet R k
Tile
172'44-f j
Owner ntractor Signature Date
CITY OF CUPERTINO
FURNACE/AC
�UPEtZTIN0 PERMIT APPLICATION FORM
APN# 3SG 3- O S Date: 7
Building Address: SOI
� � • r�'�n c q y
Owner's Name: Phone#: Sa Q
Contractor: Phone: ��) l-��� License#: -C90
� - in � 516
Contact: Phone: Sm Cupertino Business License#:
�fl�r 1Q 'J
Building Permit Info:
Bldg ❑ Elect Plumb ❑ Mech e
Job Description:
QQz,ca Ca 0/0
Residential(:� c. Commercial ❑
For Residential Installations:
ttic ❑ 1` floorCB- 2"d floor❑ ,
dhere to min set back requirement❑
For Commercial Installations:
Replacement same weight ❑ Additional weight (structural calcs) ❑
Structural Calculations required for new installation ❑
New installation Planning Approval Required ❑
Cost of Project / 6 S Type of Construction: Occupancy group:
Strapped El On Platform LJ Bonded ❑ Sq.Ft. Floor Area:
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BREMFURN Relocation of Furnace MECHANICAL
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10, 000 cfrn MECHANICAL
BREMRECEPT Rec tl, Switch & Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILIDNG
/ EPERMITFEE Elec Permit Issuance .ELECTRICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
/ BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING