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10100115CITY OF CUPERTINO BUILDING PERMIT 13111ILDING ADDRESS: 5 RESULTS WAY CONTRACTOR: i:) PERMIT NO: 101001 15 OWNER'S NAME: ECI TWO RESULTS LLC R'S PHONE: 6502924100 LICENSED CONTRACTOR'S DECLARATION License Class- Lic. b -�4 ( a Contractor 1 Mj (irq 1 G W tip � nate I herebN affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. l I ��,� f 1� U DATE ISSUED: 09/12/2011 PHONE NO: BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH I— RESIDENTIAL I— COMMERCIAL JOB DESCRIPTION: NORTHWEST CORNER OF PROPERTY - INSTAL..L. A PROPOSED MONOPINE WITH (12) PROPOSED AT&T ANTENNAS, (24) RUNS OF 7/8" COAX & (12) TOWER MOUNTED AMPLIFIERS hercbv affirm under penalty of perjury one of the following two declarations: I havc and kill maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the perfixmance of the work for which this permit is issued. I have and shill 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 i5 issued Sq. Ft Floor Area: APPLICANT- CERTIFICATION I ccrtifo 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 huilding construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save nujenuul,, and keep harmless the City of Cupertino against liabilities, judgments, cosu, and expenses which may accrue against said City in consequence of the _ranting (it this permit Additionall the applicant understands and will comply with all nim -point source regulation. er the Cupertino Municipal C de, Section y I\� \ Sl��nautre Date OWNER -BUILDER DECLARATION ,erebv affirm that 1 am exempt from the Contractor's License Law for one of the folloAing two reasons: I. a, owner of the property, or my employees with wages as their sole compensation, kill do the work, and the structure is not intended or offered for sale (Sec.7044, liusmess & 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 pertorniance ofthe work for which this permit is issued. I havc 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 ceruth that in the performance of the work for which this permit is issued, I shall not cmplo\ ani person in any manner so as to become subject to the Worker's I, ompensation laws of Cafilurnia. If, after making this certificate of exemption, I heCOmC subject to the Worker's Compensation provisions of the Labor Code, I must 10rthwuh comply \vnh such provisions or this permit shall be deemed revoked. -kPPL.ICANT CERTIFICATION I ccrtit\ that I havc read this application and state that the above information is correct I agree to coil, u Ply with all city and county ordinance, 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 indenmifv and keep harmless the City of Cupertino against liabilities, judgments, and expenses which may accrue against said City in consequence of the ung of this permit. Additionally, the applicant understands and will comply all non -point source regulatirns per the Cupertino Municipal Code, Seetiai Si_nature Date APN Number: 35720042.5 Valuation: $50000 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. Signature of Applicant: Date. ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE 1 have read the hazardous materials requirements under Chapter 6.95 of the California Ilealth & Safety Code, Sections 25505, 25533, and 25.534. 1 will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(x) should I store or handle hazardous material. Additionally, should 1 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 Ilealth & Safety Code, Sections 25505, 25533, and 25`534. Owner or au o 'z �Ir: 1 Date: CONSTRUCTION LENDING AGENCY" I herebv affirm that there is a construction lending agency for the performance of ewrk's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professiona I CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 5 RESULTS WAY I CONTRACTOR: BROKEN ARROW COMM I PERMIT NO: 10100115 I OWNER'S NAME: ECI TWO RESULTS LLC 8316 CORONA LOOP N.E. I DATE ISSUED: 09/12/2011 [OWNER'S PHONE: 6502924100 ALBUQUERQUE NM 87113 PHONE NO: (505)262-2621 LICENSED CONTRACTCO(R'S DECLARATION 14 License Class ``Lica 8— j� Contractor -01-0 �l�j� 1 I'Q yl,Gkl 6Date [ 6 —y� 12- I 2I hereby affirm that I am licensed under the provisions of Chapter 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 1 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. %f /� [ ^� Signature ' C� Date[ "�� 7 tL ❑ 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 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 BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r— MECH r RESIDENTIAL r COMMERCIAL JOB DESCRIPTION: AT&T NORTHWEST CORNER OF PROPERTY - INSTALL A PROPOSED MONOPINE WITH (12) PROPOSED AT&T ANTENNAS, (24) RUNS OF 7/8" COAX & (12) TOWER 4/3/12- REVISION #1- CONSTRUCT 6 FT RETAINING WALL -ISSUED 10/25/12 Sq. Ft Floor Area: I Valuation: $60000 APN Number: 35720042.5 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by Date: 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. O-wwr or aut a t� i(' Date: 10,Z ^ — / Z, 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 Date I I understand my plans shall be used as public records. CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 09-051 EX " 1 111 ADDRESS: ln.sp. Plumb. l ,' DATE: REVIEWED BY: Plan Check Fee: 1SUPPKFEE APN: BP#: `VALUATION: 1$50,000 PERMIT TYPE: Building Permit Suppl. PC Fee: 0 Reg. 0 OT PLAN CHECK TYPE: Tenant Improvement PRIMARY USE: Commercial Building $252.00 T(�7�11, FLOOR .4REzi PENTAMATION TELECOMFAC PERMIT TYPE: WORK SCOPE $0.00 Suppl. Insp. Fee10 Reg. 0 OT NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 09-051 EX " 1 111 Orher;lkch. Insp. ,11ech. Insp. Fee: ln.sp. Plumb. l ,' Li 7ec. Insp. Fec: NOTE: These fees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addn'1 info. FEE ITEMS (Fee Resolution 09-051 EX " 1 111 FEE QTY/FEE MISC ITEMS Plan Check Fee: 1SUPPKFEE $0.00 Select a Misc Bldg/Structure or Element of a Building Suppl. PC Fee: 0 Reg. 0 OT 2.0 hrs $252.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee10 Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Gonstruction TaxT-T- Acoustical Fee: 0 Yes 0 No $0.00 0 E) Work Without Permit? 0 Yes E) No $0.00 Planning L:ee: $0.00 12 # Antenna - Telecom Facility $12,156.00 IANTCELATT I Cellular, Attached to Bldg 0 i Travel Documentation Fees: Strong Motion Fee: IBSEISMICO $10.50 $1,158.00 Wireless Master Plan IWMPLNFE Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $264.50 13,314.00 TOTAL FEE: $13,578.50 Revised: 9/29/2010 CITY OF /c -N 32-4Z 0c) CITY OF CUPERTINO TELECOMMUNICATIONS FACILITY CUPERTMO CELL SITE -PERMIT APPLICATION FORM APN # s Fee ID Date: Building Address: Permit Type 5 jZESvi TS wW" IANTCELFREE Owner's Name: B Phone #: CGI -r'wC AE,SWlTS LLG ANOIwt, O -N IANTCELATT 650-21Z-ql(k Contractor: Phone #(A ( ) 7 - V511t T13D 1�,\ \OVA `Vo W j Q_ l Fax# Contractor License #: Cupertino Ausiness License #: Contact: DTAr/K at b,-, -7 it t 411w, B Phone #: -:� iA43LLS.15o - a p t - o *IT 4 T 1BSEISMICOM Fax #: = 2o2& Job Description: )NSTALc- A P20PI'56D M0t4QPtHC- wiTvl (j2) PQoe3.,L0 ATI T ANS/91414n) J (ZK) RvNS OF' �l'" CCA -1 PAD G -L) Tull- M41rlT"> pr,r�.�F��rt� 11 � �tICLU�►cC, V�/����%if Is the project in the Wildland- Urban Interface Fire Area? Yes No g Cost of Project:� Type of Constructio : N/A �C;01)6 Wireless Light Pole Fee (per mount) Project Size: Express ❑ Standard � Large ❑ Major ❑ Quanty Fee ID Fee Description Fee Group Permit Type IANTCELFREE Cellular/Mobile Phone Free Standing (Incl elect, 1 ck,travel) B TELECOMFAC IANTCELATT Cellular/Mobile Attached to Buildin (incl elect, 1 ck,travel B IBCBSC Cal Bldg Standards Commission Fee B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial B I LIGHTPOLE Lighting Pole E ILPOLEFEE Wireless Light Pole Fee (per mount) PL 1 WMPLNFE Wireless Master Plan Other Personal Wireless Facility PL 1 BUSLIC Business License B Revised 07/06/09 gsbC _ GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 • building(7a cupetno.org ❑PLUMBING ❑MECHANICAL ❑ELECTRICAL /MISCELLANEOUS (/ L 1 71111—f PROJECT ADDR _l IT CwtIP/I fo e-4 qSD I -{ �( e OWNER NAME PHOT Sd HY� E-MAIL --/LC STREET ADDRESS/�C i S w� e� CITY, STATE, ZIP /tsr a., for C� q YSscB FAX CONTACT NAME % f� /c, PHONE p r` _ �v G E-MAIL /t STREET ADDRESS[ GF� !/om /�el J CITY, STATE ZIP/`��s/�!� �i� 9 --JS g� FAX Kd0 ❑ OWNER ❑ OWNER -BUILDER - e'OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME % (N\ d WQ% LICENSE NUMBER ' f 01 1 -1 d� LICENSE TYPE BUS. LIC # A U COMPANY NAME pC �vrjqr o�✓tr E-MAIL i ' / ��a EJ R : ivn . c& FAX /f9 STREET ADDRESS -3 �( , �.��STk 1 !ra! CITY, STATE, ZIP �✓� i /'w...:G c� 9 S�G qI PHO 11/Gi 3 ARCHITECTIENGINEER NAMV /�v m G LICENSE NUMBER / _ O� BUS. LIC £1 COMPANY NAME E-MAIL. F�C( /lp STREET ADDRESS / lR� J CI ,STA TE, ZII' �a 0 USE OF ❑ SFD or DUPLEX ❑ MULTI AMMY BUILDING: ❑ COMMERCIAL PROJECT IN WILDLAND YES URBAN INTERFACE AREA ❑ NO PROJE iN ❑ YES FLOOD ZONE ❑ NO IS THE BLDG AN ❑ YES EICHLER HOME? ❑ NO DESCRIPTION OF WORK / �� ��v �� ( I r ! f�7►rl (% rr� es. J TOTAL VALUATION: j0 ae C', RECEIVED BY: By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct., j.have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building construc ' auth n of Cupertino to enter the above -id fled p perry for inspection pufposes. Signature of Applicant/Agent: Date: ���� SUPPLElVENTAL INFORMATION REQ=D OFFICE USE ONLY w ❑ OVER-THE-COUNTER Y ❑ EXPRESS U U ❑ STANDARD ❑ LARGE 4 ❑ MAJOR MEPMIscApp_1011.doc revised 06121111 17 . adn CITY OF CUPERTINO I�YI FEE ESTIMATOR - BUILDING DIVISION ia, ADDRESS: Results Way DATE: 04/03/2012 REVIEWED BY: Sean APN: BP#: `VALUATION: 1$10,000 SPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Addition / Repair PRIMARY USE: Commercial Building i'lumb. Insp. T:< PENTAMATION PERMIT TYPE: 1CBCR WORK Construct a 6' retaining wall 64' in length) at existing cell site. SCOPE NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc )_ These fees are hated on the nreliminary information available and are onlv an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolulion 11-053 Eff 71,71) FEE !'hwib. Phm ('heti, MISC ITEMS Plan Check Fee: 01/1r'r Mech. Insp. 01lier Plumb Imp. Other Llec. Inst, ED Mech. h�, Fee: i'lumb. Insp. T:< f 0. 01 NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School District. etc )_ These fees are hated on the nreliminary information available and are onlv an estimate. Contact the Dent for addn7 info. FEE ITEMS (Fee Resolulion 11-053 Eff 71,71) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 = l.f. $1,435.00 Retaining Wall 1RETSTN Standard Retaining Wall Suppl. PC Fee: Q Reg. Q OT f 0. 01 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee:Q Reg. Q OT Fo,Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Conswuction Tax: 1(%lninistrotin Fc, Work Without Permit? Yes No $0.00 Advanced Planning Fee. $0.00 Select a Non -Residential Building or Structure E) � Travel Documentation Fees: Strong Motion Fee: IBSEISMICO $2.10 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $3.101$1,435.00 TOTAL FEE: 1 $1,438.10 Revised: 1/19/2012 CUPERTINO CONTRACTOR / SUBCONTRACTOR LIST Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408-777-3228 Fax: 408-777-3333 *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 Owner / Contractor Signature Dat California Contractors Lie. 794622 October 24, 2012 City of Cupertino Permit # 10100115 Address: 5 Results Way Cupertino CA Please consider this official authorization to transfer the referenced building permit out of Triton Tower Inc. name and into the new contractor, Broken Arrow's name. Should you have any questions, please feel free to contact us at 916-375-8546. Sincerely, Kevin Wingard Triton Tower, Inc 3124 Industrial Blvd., West Sacramento, CA 95691 Phone (916) 375-8546 Fax(916)375-8537 CORPORATE 8316 Corona Loop, NE Albuquerque, NM 87113 (505) 877-2100 (505) 877-2101 Fax www.bacom-inc.com Arizona Office 230 S Date St. #101 Mesa, AZ 85210 (480) 966-0450 (480) 966-0838 Fax California Offices 3160 Scott Street Vista, CA 92081 (760)918-0551 960 Brook Street Ontario, CA 91762 (909)355-9300 (909) 988-8061 (909)988-983-2316 Fax 4970 Allison Parkway #D Vacaville, CA 95688 (707) 417-2469 (707)447-5974 Fax Nevada 1201 American Pacific Dr Suite C Henderson, NV 89074 (702) 564-9667 (702) 446-8104 Fax Utah 100 North 700 West, Ste C N. Salt Lakc, UT 84054 (801) 936-1020 (801) 936-1043 Fax val 9lrl/I: _`Ao— California Contractors Lic. 85361 October 25, 2012 City of Cupertino Pennit# 10100115 Address: 5 Result Way Cupertino T10 Please consider this official authorization to transfer the referenced building permit out of Triton Tower name into Broken Arrow's name. Please call with any questions at 707-447- 2469.