10110070 UI TY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10555 MARY AVE CONTRACTOM4131)"211RE
PERMIT NO: 10110070
OWNER'S NAME: CITY OF CUPERTINO WILSON PARK
ATE ISSUED: 12/22/2010
OWNER'S PHONE: 4087773407
PHONE NO:
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL [JLOCATED @MAINTEN NCE-PROPOSED WIRLESS FACILITY
License Class Lic.# ADDING 3 PANEL ANTENNAS,3 RADIO RECEIVING UNITS&
3 MICROWAVE ANTENNAS. I EQUIPMENT CABINET INSIDE
Contractor
ate_&/22
1 hereby affirm that 1 am licovisions 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.
1 hereby affirm under penalty of perjury one of the following two declarations:
1. I have and will maintain a certificate of consent to self-insure for Worker's Sq•Ft Floor Area: Valuation:$30000
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. APN Number:326060521.00
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by Occupancy Type:
Section 3700 of the Labor Code,for the performance of the wprk4or which this
permit is issued.
APPLICANT CERTIFICATION PERMIT EXPIRES IF WORK IS NOT STARTED
I certify that 1 have read this application and state that the above information is WITHIN 180DAYS OF PERMIT ISSUANCE OR
correct.I agree to comply with all city and county ordinances and state laws relating 180 DAYS FROM LAST CALLED INSPECTION.
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, Issued by: Date:
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 rce regulations per the Cupertino Municipal Code,Section 9.18.
RE-ROOFS
Signature ate_/7 A 2//0 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.
0 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant:_ Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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) HAZA(RDOUS MATERIALS DISCLOSURE
2. 1,as owner of the property,am exclusively contracting with licensed contractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupe{tino Municipal Code,Chapter 9.12 and the Health&
I hereby affirm under penalty of perjury one of the following three declarations: Safety Code,Section 2553�(a)should I store or handle hazardous material.
1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's Additionally,should I use Equipment or devices which emit hazardous air
Compensation,as provided for by Section 3700 of the Labor Code,for the contaminants as defined b�the Bay Area Air Quality Management District I will
performance of the work for which this permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
2. I have and will maintain Worker's Compensation Insurance,as provided for by Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this Owne thorized a
permit is issued. 22
3. 1 certify that in the performance of the work for which this permit is issued,1 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 CONSTRUCTION LENDING A ENCU
become subject to the Worker's Compensation provisions of the Labor Code,I I hereby affirm that there is a construction lending agency for the performance of work's
must forthwith comply with such provisions or this permit shall be deemed for which this permit is issued(Sec.3097,Civ C.)
revoked. Lender's Name
Lender's Address
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 ARCHITECT'S DECLARATION
to building construction,and hereby authorize representatives of this city to enter I understand my plans shall be used as public records.
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Licensed Professional
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