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10070193 CITY OF CUPERTINO BUILDING PERMIT B1111,DING ADDRESS: 10730 N BLANEY AVE CONTRACTOR:MT2 TELECOM,LLP PERMIT NO: 10070193 L ER'S NAME: CUPERTINO MINI WAREHOUSE PARTN 3780 C JMMERCE DR DATE ISSUED:07/29/2010 OWNER'S PHONE: 4082572900 W SA(RAMENTO,CA 95691 PHONE NO:(916)376-8555 ❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r- PLUMB r License Class Lic.# Z`7 0 OT MECH r RESIDENTIAL r COMMERCIAL r ContractorM}Z' '��t��'c��~t AI P,Date 'Z`7 to I hereby affirm that I am licensed under the provisions o Chapter 9 EOBT1 DESCRIPTION: INSTALLATION OF A FIBER MODEM BOX INTO AN (commencing with Section 7000)of Division 3 of the Business&Professions LEASE AREA OF AN EXISTING CELL SITE 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 Sq.Ft Floor Area: Valuation:$4000 permit is issued. APPLICANT CERTIFICATION APN slumber:31643009.00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR costs,and expenses which may accrue against said City in consequence of the granting of - nit. i ,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all n-p ' t s u` re ati er the Cupertino Municipal Code,Section 9.18. Issued Date: star Date ❑ OWNER-BUILDER DECLARATION RE-ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All ro As shall be inspected prior to any roofing material being installed.If a roof is the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, inspe(tion. will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) Signa are of Applicant: Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: HAZARDOUS MATERIALS DISCLOSURE 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 I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. Calif)rnia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain I have and will maintain Worker's Compensation Insurance,as provided for by coml liance with the Cupertino Municipal Code,Chapter 9.12 and the Health& Safety Code,Section 25532(a)should I store or handle hazardous material. Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air permit is issued. conts.minants as defined by the Bay Area Air Quality Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain compliance 'th the Cupertino Municipal Code,Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker'sH Safety C de, ons 25505,25533,and 25534. 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 Owne o ed - d( l Date: forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is I her;by affirm that there is a construction lending agency for the performance of work's �--rect.I agree to comply with all city and county ordinances and state laws relating for H hich this permit is issued(Sec.3097,Civ C.) tilding construction,and hereby authorize representatives of this city to enter Lender's Name ,,on the above mentioned property for inspection purposes.(We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address costs,and expenses which may accrue against said City in consequence of the granting of this pennit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. I unc.erstand my plans shall be used as public records. Signature Date Licensed Professional c CITY OF CUP ERTINO CUPERTINO GENERAL BUILDING PERMIT APPLICATION FORM APN# _� � I � v ( � Date: � --n �Z.C.9 �.. Building Address: 3 A0ZZ1A)6,Z�_-_)Z 2 d C UPZ_P_FI AUC CA- Mailing Address (if different from building address): Q/ Are Hazardous Materials being used as part of this project? Yes ❑ No HOA: (Exterior work only) Yes ❑ No ❑ If yes, rovide letter from HOA Owner's Name: Phone#: n9:l 1_ I CLIOS)V 7 -(D70 Contractor: O hone: tJ 2 Fax: Contractor License#: Cupertino Business License#: Contact: Phone: Fax: Residential Commercial ❑ Job Description: cJ�]—� C (� A L L Ro U �,) D T �F � NEL 1_­LLJCT1z LG QKF �C& RS Building Permit Info:/ C - 7_0 C( V ' Bldg ®� Elect Plumb ❑ Mech ❑ Type of Construction (Usage Class): Occupancy Type: —3 1-A 1-B II/III/V-A IVIII B IV-HT V-B Valuatior& ® © Square Footage: Project Size: Express Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building/LEED Checklist& attach it to the application or if applicable, include in plan set& the sheet index. 'oints Achieved: For help, contact Build it Green at www.builditgreen.or Revised 07/14/09 i M.Indoor Air Quality andFinishes- 1- ins es 1.17sbIbAllJo-vocPad t 1 IACMiealth pts y--yes 0 2.Use Low VOC,Water-Based Wood Finishes 21AW-Wealth pts Y--yes, 0 3.Use Low/ND VDC Adhesntes 3 IAQA4ealth pts y=yes 0 4.Use Salvaged Materials for Interior Finishes 3 Resc urce pts y=yes 0 5.Use Engineered Sheet Goods with no added Urea Formaldehyde 61AQAiealth pts y=yes D 6.Use Exterior Grade Plywood for Interior Uses 1 IAQ/liealth pts y--yesD �,deal all Exposed Par#iclebcsard or MDF 4 IAQA iealth. pts y=yes 0 B.Use FSC Certified Materials for Interior Finish 4 Resc urce pts yeses 0 9.Use Fnger-Jointed or Recycled-Content Trim 1 Resc urce pts y--yes; 0 10.Install Whole House Vacuum System 3 IAO-jHealth pts y=yes D 1 1 1 N.Flooring 1.Select FSC Certified Wood Flooring 3 Re501 rce pts y=yes 0 .Use flaplly.Renewable Flooring Materials 4 Resoc rce pts y--yes 0 3.Use Recycled Content Ceramic Tiles 4 Resoc rce pts y=yes 0 4.Install Natural Linoleum in Place of Vinyl 5 IAQ/I-ealth pts y=yes 0 5.Use Exposed Concrete as Finished Floor 4 ResOL rce pts y=yes D 6.Install Recycled Content Carpet with Low VOCs 4 Resol rce pts y--yes0 Total Points Available: 1401 130 57 Total Points Project Deceived: 0 0 0 kap �Z- 7 � Mdatalprogs/gresnbuildngi uiderines/remodelerslgreenpointsfina1212D4protaotedxis OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO,CA 9E,014-3255 (408)777-3228•FAX(408)777-3333•bulidln )QnCUDBrtlno.oro CUPERTINO Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS (�/ 1`i Q AP N B P# OWNER NAME r_ ( OWNER ADDRESS /' '� 6©L L n � � C9 DESCRIPTION OF WORK: F O C G v lou •6L We are providing you with an Owner-Builder Acknowledgment E nd Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision,signed,and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you,the property owner, obtain the prior approval of the permitt ng authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS:Please read and initial each statement below fc signify you understand or vek. rify this information.) 1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner- ` ing his or her own labor and material Builder"building permit that erroneously implies that the property owner is provid personally. I, as an Owner-Builder, may be held liable and.subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. 2. I understand building permits are not required to bE signed by property owners unless they are responsible for the construction and are not hiring a licensed Contractor tc assume this responsibility. &63. I understand as an"Owner-Builder" I am the responsible party of'record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. 6L& I understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. U5. 1 understand if I employ or otherwise engage any r ersons,other than California licensed Contractors, and the total value of my construction is at least five hundred dollars($500), including labor and materials, I may be considered an "employer"under state and federal law. •0 6. 1 understand if I am considered an"employer"and 3r state and federal law, I must register with the state and federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each"employee." I also understand my failure to abide by these laws may subject me to serious financial risk. 7. I understand under California Contractors' State L cense Law,an Owner-Builder who builds single-family residential structures cannot legally build them with the in:ent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures doE s not exceed four within any calendar year, or all of the work is performed under contract with a licensed general buildi-ig Contractor. A•E 8. I understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for any financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction defects in the workmanship or materials. 0;l1rter Bui(derFornt_2010.doc revised 04/14/10