10030061 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10121 MILLER AVE CONTRACTOR:MT2 TELECOM,LLP PERMIT NO: 10030061
OWNER'S NAME: D&D REAL ESTATE LT 3780 COMMERCE DR DATE ISSUED:03/10/2010
NER'S PHONE: 4082554100 W SACRAMENTO,CA 95691 PHONE NO:(916)376-8555
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r— ELECT r— PLUMB�
License Class Lic.#
MECH F_ RESIDENTIAL[_ COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:INSTALLATION OF FIBER MODEM BOX INTO AN
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING
Code and that my license is in full force and effect. CELL SITE LEASE AREA
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 Number:36907001.00 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,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:71-�U�U
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs 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
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature 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:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
contaminants as med 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 m Iro
lance ith the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's eety Sections 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 mus Owtho iz agen
forthwith comply with such provisions or this permit shall be deemed revoked. Date: (7
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
unify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
.,and expenses whic a a e against said City in consequence of the
granting o 1 it. dditi I the applicant understands and will comply
with all on-p in s e reg er the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. I understand my plans shall be used as public records.
Signa "-"—�' Date
Licensed Professional
CITY OF CUPERTINO
6 ITEMS OF 36 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot :
APN 36907001. 00
DATE ISSUED. . . . . . . : 03/10/2010
RECEIPT # . . . . . . . . . BS000009910
REFERENCE ID # . . . : 10030061
SITE ADDRESS 10121 MILLER AVE
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER D&D REAL ESTATE L.P
ADDRESS . . . . . . . . . . : 10121 MILLER AVE
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : CHAD D CHRISTIE
CONTRACTOR JON MORENO LIC # 31419
COMPANY MT2 TELECOM, LLP
ADDRESS 3780 COMMERCE DR
CITY/STATE/ZIP . . . : W SACRAMENTO, CA 95691
TELEPHONE (916) 376-8555
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------
1BCBSC VALUATION 4, 000 .00 1 . 00 0 .00 1 . 00 0 . 00
1BSEISMICO VALUATION 4, 000 . 00 0. 84 0 . 00 0 . 84 0 . 00
1EPERMITFE FLAT RATE 1.00 42 . 00 0 . 00 42 . 00 0 . 00
1MECHINSP HOUR 1 . 00 126 . 00 0 . 00 126 . 00 0 . 00
1MPERMITFE FLAT RATE 1. 00 42 . 00 0 . 00 42 . 00 0 . 00
1TRAVDOC FLAT RATE 1 . 00 42 . 00 0 . 00 42 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 253 . 84 0 .00 253 . 84 0 . 00
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CITY OF CUPERTINO
CITY Of
CUPERTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
l.Qc1 C) Ob I . DU /o
Building Address:
O 12-V 1M I Lee— AV
Mailing Address (if different from building address):
Are Hazardous Materials being used as part of this project? Yes ❑ No
HOA: (Exterior work only) Yes ❑ No ❑ If yes, provide letter from HOA
Owner's Name: Phone#:
Contractor: _ Phone:
Fax:
Contractor License#:
Cupertino Business License#:
Contact: Phone:
C a rA d C Fax:
Residential ❑ Commercial
Job Description:
a r.J b F A FigE9,— ►v1 odJE.ek QOK
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, 1-B ❑ IUIII/V-A ❑ II/111 B, IV-HT, V-B ❑
Valuation:$ , 01-D Square Footage:
0 0�
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.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 07/14/09
J CITY OF CUPERTINO
Cin OF GENERAL BUILDING APPLICATION
CUPERTINO
FEE SCHEDULE
Quantity/Sf Fee ID Fee Description Fee Permit Type
Group 1GENRES or
1 GENCOM
1STUCOAP Stucco Applications (up to 400 so B
additional stucco application
1 WINREP Replacement windows/sliding glass B
door (ea 8 windows)
1 WINMEWSTR New Window-structural shear B
wall/masonry(includes plan ck fee)
/ 1 EPERMITFEE Electrical Permit Fee E
/ 1 MPERMITFEE Mechanical Permit Fee M
I 1 PPERMITFEE Plumbing Permit Fee P
1 ELCPLNCK Stand Alone Electric Pln Ck (hourly) E
1 MECPLNCK Stand Alone Mechanical Pln Ck (hrly) M
1PLMBLNCK Stand Alone Plumbing Pln Ck (hrly) P
1 STPLNCK-(3 Hr Min Standard Plan Check (when no E/M/P) B
when not over counter) hourly-stand alone
1BCBSC Cal Bldg Standards Commission Fee B ALL PERMIT
TYPES
1BSEISMICR Seismic Residential B
1BSEISMICO Seismic Commercial B
1 TRAVDOC Travel &Documentation B
1BUSLIC Business License B
5 of 5
sa Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
'UPEKTINO
BW1 in De artment
JOB ADDRESS: PERMIT #
0 12 P4 LL--A- � le2o � 1
OWNER'S NAME: ID VL2cA 1�3-JPHONE # ell
GENERAL CONTRACTOR: 'TL FAX #
I am not using any subcontractors:
Signature Date
Please check ap licable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date