07020144 777777777777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
EC20M AGT�RI�ORM�4TIQN:
BUILDING ADDRESS: PERMIT NO.
21070 RAINBOW PL VALLEY HEATING & COOLING 07020144
OWNER'S NAME: PERMIT ISSUE DATE
RAMESH RIO 1171 N 4 TH ST 02/27/2007
_)NE. SANITARY NO. CONTROL NO.
(408) 254-6290
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
p C LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and m license is REPLACEA C
Q- in full force and cft et)—
r ? Licensc CI a Lic.#
y Date Contractor
ARCHITECTS DECLA All
7 C< 1 understand my plans shall be used as public records
.0.
G y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.t 0
which requires a permit to construct alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area
j I--O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5900
5 9 O O
U52 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Number Number Occupancy Type
not more than five hundred dollars WWII. 3 6 6 2 6 0]
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for We.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and•
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
C]I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's persation Insurance carrier and Policy number are:
Carrier, i/ Policy No.:
CERTIFICATE OF EXEMPTION FRO WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z J" CONSTRUCTION LENDING AGENCY
(� I hereby affirm that there is a construction lending agency for the performance of
p( > the work for which this permit is issued(Sec.3097,Civ.C.)
CW Q Lender's Name
z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
Li.► correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City or Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
�+ APPLICANT UND RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE TI NS.
�- Re-roof:. 2-
Hat� fAppffcant/Coniractor Dam Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
Cl Yes
ng cupan
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or Tutbuild' OC t use equipment or devices which
emit hazardous air contaminansu defined by the Bay Area Air Quality Management all new naterials for inspection.
District?
❑Yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently ha a tenant.that it is my responsibility to notify the occupant Of the
rcyuireme ust be met prior once of a Certifica ar apaney. Signatul e of Applicant Date
All roof coverings to be Class "B"or better
Own or aur ri-zed Da
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
`;UPE�TIN0
Building Department
JOB ADDRESS: j7PERMIT #
OWNER'S NAME: / PHONE # —
GENERAL CONTRACTOR FAX #
I am not using any subcontractors:
-c.i ature Date
Please check applicable subcontrac rs 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
bi, er%Qontractor Signature Date
CITY OF' CUPERTINO
5 ITEMS OF 5 PERMIT RECEIPT OPERATOR: amyw
COPY # 1
Sec: Twp: Rng: Sub: B]k: Lot:
APN . . . . . . . . . 3( 626030. 00
DATE ISSUED. . . . . . . : 0z' /27/2007
RECEIPT #. . . . . . . . . . BS000000553
REFERENCE ID # . . . : 0, 020144
SITE ADDRESS . . . . . : 21070 RAINBOW PL
SUBDIVISION . . . . . .
CITY . . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . . F-IMESH RIO
ADDRESS . . . . . . . . . . : 21070 RAINBOW PL
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : ATKINSON, THOMAS LIC # 141
COMPANY . . . . . . . . . . : VI,LLEY HEATING & COOLING
ADDRESS . . . . . . . . . . : 1171 N 4 TH ST
CITY/STATE/ZIP . . . : S7N JOSE, CA 95112
TELEPHONE . . . . . . . . . (408)294-6290
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- - --------- ---------- ---------- ----------
BENERGY PERMIT FEE 1. 00 34 .86 0. 00 34 . 86 0. 00
BREMAIRHAN NO.UNITS 1. 00 10 .26 0. 00 10.26 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
PPERMITFEE FLAT RATE 1. 00 38.37 0. 00 38.37 0. 00
- --------- ---------- ---------- ----------
TOTAL PERMIT 160 .23 0. 00 160.23 0. 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 160.23 15934
---------------
TOTAL RECEIPT 160.23
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
303 ROUGH MECHANICAL 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL 508 FINAL MECHANICAL
I
1
CITY OF CUPERTINO
0-1020 1 q4
FU R44ACE/AC
CUPl t[NO PERMIT APP]__JICATION FORM
APN# Date:
a - of
Building Address: CA 01St
Owner's Name: Phone#:
Contractor: License#:
H2_
ontac : Cupertino Business License #:
1
Building Permit Info:
Bldg ❑ Elect Plumb E– Mech
Job Description: n-
!'c
Residential CIS Commercial ❑
For Residential Installations:
Attic ❑ 1St floor ❑ 2°d floor ❑
Adhere 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: Type of Constn ction: Occupancy �up:
SAW �).
Strapped El On Platform a Bonded 91 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 cfm MECHANICAL
BREMRECEPT Rec tl, Switch& Outlets ELECTRICAL
BSEISMICRE Seismic Fee Res BUILDING
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