03120124 CITY OF CUPERTINO Mkt].:.^L:.�rs "tnr"-r�r�rya�+ "�"L�k,�
BUILDING DIVISION PERT #� �`I''L-. .A-..%�`1R4�41i >L4�Y1� .T0
BUIL"
ADDRESS: METROPOLITAN ELECTRICAL CO RlIIT NG)3120124
191 MTTTP.R AIT
OWNER'S NAME: PERMIT 1SSUEDATE
('TMC,TJT.AR WTRF.T,Pq.(; 2400 THIRD ST 4
E, SANITARY NO, CONTROL NO.
(415) 642-3000
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGO EO PLO O
30 MECH
p LICENSED CONTRACTOR'S provisions DECLARATION Job Descri tion
hereby efO r tNs 1 am Ifcemed unJer ndPof Chapter 9 fcrmme..1, P
with5 on] )of DlWion7afthe 0utinpasand Profeulonc Code.and myllccnxe is
ni in run to o f.,. L .0 ply" WIRELESS ANTENNA CELL SITE
q z_ Lieen
Da Co.on
r
RCHf1ELTS D
1 understand my plans shall he used u public records
J
G
Licensed Professional
OWNER-BUILDER DECLARATION
0� I hammy affirm on I eo
exempt froms an the Comasnora License Law for the
00 fallowing moon.peva dun]117 1.3,Bualnut and r mfdero t Cole:Any oily or county
$� which requiresapermit toconsumer,the alter.hnpmsudech ermitt inrepaira siganyshalum
z y prior o its ceased pit eta requires the applicant o for Cmimscmiuo iesew Law
(Chapter
g < that he(commencing eJpursusntotheofDisil3ofe eBusinwraLmnnlsiw(Clupurr9 Sq.Ft.Floor Area Valuation
may $ teat he is
(commencing Section11100)ad of basis
3 the
theeged Business and ProfusionsCode)Of $80000
that he ts exempt Ihre(rom and the btu for the alleged emmption.My violation of
Section 7031.5 by by application for a permit subjects the applicant o a civil penalty of APN Number Occupancy e
not more Than Ove hundred dollars($700). P Y `7y J P
❑I,uownaorthcpmpemymmyemploycuwiN"w uthirmlecompenntim,
will da NewmlC and ft structure been lmendedmoRamd fa...le(Sec.7DOI.BY561eti aired Inspections
and Profeselom Code:Thn roo a
This Commence,License Law dot apply an Owner of 9 P
property who bui lds or l m prow Noreen,and who de a such work himself or through his
awnemploy en,provided dunauch lmprememenls an,not inunded reoffered forule.If,
however.the building or improvement is sold within one you of eampleuon,the owner;
builder will hove the burden of proving east me did Out Wild or impmme(mpurywdof ( '-
sale.). \\ U
❑1.as Owner of the propeny.atm exclusively contracting wjb licensed contractors to
consumer the praises(Sec.7044,Business arm Profusion,Codel)The CpnuanN't Li-
cense Law does not apply to on owner of property who Wilds dr IFPMdthere and
who contracta far such projects with.comrmoo.)licensed panic eCon a
License Law.
❑I am exempt under See POf t su+ort
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby aflbm under peuey of perjury one of the following declensions:
have and will maintain a Ceemuur of Consent w sal(-Insure for WarkeesCompen-
adan.as providod for by Section 37M of the Labor Code,for the performance of the
wart for which this permit is issne0.
O 1 hive and will maintain Workers Compensation Insurance,as required by Section
37M of the L Wr Code.for eac performance of the wart for which this permit is issued.
My retort Cnmpemation Insurance mmier and Policy nu rare:
q tin V
/}M�faGM /:J.f.t.YSPaIIty No.. F f ll
CERTIFICATE OF EXEMPTION WORKERS'
COMPENSATION INSURANCE
f7665mtion need not bucompleud if the permit is Toter hoodreddollara(SINE
or less.)
1 certify that in the performance of the work fm which this permits is issued,l shill not
employ any Form.in any manner m u in become subject to the Workers'Compctrsatlan
Lows of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Candlish,of Exemption,you should
become subject In the Wortmi Campcuation itmisimts of the Labor Code,you must
wJ forthwith comply with such proormom or this permit shall W deemed revoked.
z 0 CONSTRUCTION LENDING AGENCY
[-r (hereby air,rue that Nett is a consVuctinn lending egemy for the perfurmu¢of
IY> the.,it for which this permit ts issued(Sec.3097,Civ.C.)
tiO Lenders Name,
z Leader.Add.
U Q 1 certify that I have mad this application and state that the show information is
D. enema I agree m comply with ill City and county ordinances and sour law,relating Or
O Wilding construction,and hereby suflorim mpmscouuvu of this city to cnur upon be
W above-mentioned property for inspection Purpmea
G (Wa)agree to saw,indemnify and keep harmless the City of Cupertino!lair
In Ihbllfun,judgmenu.casts and expenses which may In any way scene against mid City
V 7 in cmnequence of be momiq of this permit.
Fi APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL TIONyy.
. Re-roofs
aorto canUContracur Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WI applicant or future building mcupantstore or handle harardom mah,dil
Uy the Cupertino Municipal Code.Chapter 9.13.W the Health and Safety
ada.Smdon 235320)7
C1 Y. All roofs shall be inspected prior to an roofing material being
installed,
XN
If a roof is installed without first obtaining an inspection,I agree to remove
Will be applicant or upon,building occupant use,eyvipment or devices which
.0 lardom air contaminants u defined by tie Bay Area Air Quality Management all new materials for inspection.
Diet
❑Yes �u
1 have reW the h.S eb.. 530.2 533ardc55 unJer Chepurr6.97of Ne Glding /
.is Health Safety Ce himandons 3770alsonfmmunts unirChasmnd Nuifthe Willing
Juts n ,cumeady have a u rent.that it is my responsibility to noul'gbe nee ort or the
requimrncnu hichm mm oissuateeohCcnifh,auro(�QflxiSu_ Signature of Applicant Date
rte mautham ant am All roof coverings to be Class"B"or better