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11050221CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10110 CALIFORNIA OAK WAY ;R'S NAME: PG&E CONTRACTOR: NOR CALI PERMIT NO: 11050221 COMMUNICATION & 5130 FULTON DR STE M I DATE ISSUED: 10/06/2011 OWN'ER'S PHONE: 5105046879 1 FAIRFIELD, CA 94534 I PHONE NO: (707) 294-2051 ❑ LICENSED CONTRACTOR'S DECLARATION License Class y Lie. #�; Contractor �IdQ�� W��I�CA ate lCapter I hereby affirm that I am licensed under the provisions Vof 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source eguI tions er the Cupertino Municipal Code, Section 9.18. c .Te / Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to " ling construction, and hereby authorize representatives of this city to enter U, a above mentioned property for inspection purposes. (We) agree to save inocrnnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. BUILDING PERMIT INFO: BLDG ELECT r PLUMB r MECH r— RESIDENTIAL F COMMERCIAL JOB DESCRIPTION: AT&T - ADDING 3 ANTENNAS TO AN EXISTING TELECOM TOWER Sq. Ft Floor Area: I Valuation: $25000 APN Number: 34263001.CELL I Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTIOON. Issued b . - RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. p o /MA CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of %wrk's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Add ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Signature Date I Licensed Professional CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10110 CALIFORNIA OAK WAY CONTRACTOR: NOR CAL PERMIT NO: 11050221 COMMUNICATION & OWNER'S NAME: PG&E 5130 FULTON DR STE M DATE ISSUED: 10/06/2011 OWNER'S PHONE: 5105046879 FAIRFIELD, CA 94534 PHONE NO: (707) 294-2051 ❑ LICENSED CONTRACTOR'S DECLARATION License Class & & I&A Lic. N Contractor h094911 a 110 `Y t -Date I hereby affirm that I am licensed under the provisions of C apter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source egul tiros er the Cupertino Municipal Code, Section 9.18. Signature Date9A&� I L. -I — ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1, 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 & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. Signature Date BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB r— MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION: AT&T - ADDING 3 ANTENNAS TO AN EXISTING TELECOM TOWER Sq. Ft Floor Area: Valuation: $25000 APN Number: 34263001.CELL Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued b D a t W RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Signature of Applicant: Date: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed P Iib,5oZz� CONSTRUCTION PERMIT APPLICATION Is COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 CUPERTINO (408) 777-3228 • FAX (408) 777-3333 • building(rDcupertino.org n NF.W CnNSTRI ICTTCIN 7 AnnTTTIIN Rf AT TPR ATT01-J / TT I—I RFVTSToN / nF.FF.RRF.D ORTGTNAT. PF.RMTT (t PROJECT ADDRESS 101)-c> L r'POi2- (,AF ('N� (�� APNN _ � L4 Z 12— 2— OWNER NAME LS PHONE10 � - / $ o E A, STREET ADDRESS r n " cT �r 3� CITY, STATE, ZIP It( FAX CONTACT NAME� l� Z( PHONF�J (Z-ZrJ l�O ME� CH.LC-&SAICUNI MPvL.CrAr\ STREET ADDRESS -T �� 9v'2/tA_S) Qc SiY l $Z CITY, STATE, Z ASA..I �Dr 4 � FAX ❑ OWNER ❑ OWNER -BUILDER . A OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS. LIC H COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME TUD r l /;rS (oL PrI LICENSE NUMBER _ �7 I L /Q % l"(TIir-( BUS. LIC N COMPANY NAME�ji "�P,CI!,G �Sdr�1VICSS E-MAIL r-AAD,AA TA1� AMALTi (lt.C�r1 FAX STREET ADDRESS 3g2� ' r ?y� _� l � l I + CITY, STATE, ZIP y� � 1�� ^ A �Y5 T C JT PHONE ZVI 1 DESCRIPTION OF WORK Q4ei Ga Ard c�K tSi I✓ lits SS I l-lT EXIS,xt ?6r 4-57 T1LA A'tAt 5►or-( ��caS31 04UTCr AATS/,(r(A 9441 S o,?mm-cT- A;�S�r : 1 ra) Rb A: -72- CAS A ST 2 Y0I1-es6L-CA&t A5TS 0-4 6601 Za5 t rts,P5- PJ usu. Nrre51 �csT• EXISTING USE PROPOSED USE CONSTR TYPE N STORIES // �' EXISTG NEW FLOOR DEMO TOTAL j %f O /' �/ / AREA AREA AREA NET AREA /J �Y / // BATHROOM KITCHEN OTHERI�� REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: ❑ DETACH l rrii i I �� ❑ ATTACH N DWELLING UMTS: IS A SECOND UNIT YES SECOND STORY YES BEING ADDED? ❑ NO ADDITION ❑ NO PRF -APPLICATION ❑ YES IF YES, PROVIDE COPY OF PLANNERS NAME: l� Y PLANNING APPLr ❑ NO PLANNING APPROVAL LETTER By my signature below, I certify to each of the fo wing: I am the property owner or authorized agent to act on the property owner's behalf I have read alis application and the information I have provid9dis,9brrect. I have re the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to build' co ction. I autho ' representatives of Cupertino to enter the above -id ntified p perry for inspection purposes. Signature of Applicant/Agent: Date: Z 1 SUPPLEMENTAL INFORMATION REQUIRED i% �III� rr1/ «ro r1r11f11f Ifrttri«rr r��1 aNew SFD or Multifamily dwellings: Apply for demolition permit forexisting building(s). Demolition permit is required prior to issuance of buildingpermit for new building.,j Bldgs: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as of this � � �/ J ,Commercial Am,,", � part project. ��f _ Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application. B1dgApp_2011.doc revised 03/16/11 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 JOB ADDRESS: lQl Cc,(`,%&x .-L 0 PERMIT # O SO 2Z� OWNER'S NAME: V G k F_ PHONE # D-2 ;Z9 Y GENERAL CONTRACTOR: Q C AL Cd§! . BUSINESS LICENSE # ADDRESS: / iL'Z 5 Al CITY/ZIPCODE: VA fly VIM6 *Our municipal code requires all businesses working in the city to have a City of Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE . SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Please check applicable subcontractors and complete the following information: Date V SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring / Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Date FM-7 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NnTF.- Th PRP foo -v aro ha.QPd an /ho nroliminary Infnrmailnn aval/ahln and aP0 nnly an octi INO_ rnn/aM /ho Don/ for addn'1lnfa. FEE ITEMS (Fee Resolution 09-051 E . 7/1/10) ADDRESS: 10110 califomia oaks way DATE: s--2 ,L/, REVIEWED BY: bobs. APN: BP#: *VALUATION: 1$25,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building USE: Suppl. PC Fee: (F) Reg. 0 OT PENTAMATION TELECOMFAC PERMIT TYPE: wORK install 3 new antennas to an existing telecom tower. SCOPE NnTF.- Th PRP foo -v aro ha.QPd an /ho nroliminary Infnrmailnn aval/ahln and aP0 nnly an octi INO_ rnn/aM /ho Don/ for addn'1lnfa. FEE ITEMS (Fee Resolution 09-051 E . 7/1/10) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: (F) Reg. 0 OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee -0 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Acoustical Fee: 0 Yes (F) No $0.00 0 0 Work Without Permit? Yes (E) No $0.00 Planning Fee: $0.00 3 # Antenna - Telecom Facility $3,039.00 IANTCELATT Cellular, Attached to Bldg Strong- Motion Fee: IBSEISMICO $5.25 Select an Administrative Item Bldg Stds Commission Fee: 1BCBSC $1.00 SUBTOTALS: $6.251$3,039.00 TOTAL FF: 1 $3,045.25 Revised: 04/29/2011