15030001I CITY OF CUPERTINO BUILDING PERMIT I
1 BUILDING ADDRESS: 10050 S DE ANZA BLVD I CONTRACTTOR:IOVERLAND I PERMIT NO: 15030001
OWNER'S NAME: CH CUPERTINO OWNER LLC 1587 SIGMAN RD NE I DATE ISSUED: 07/23/2015 1
OWNER'S PHONE: 4082538900 ICON YERS, GA 30013 1 PHONE NO: (678) 413 -0333 1
0 LICENSED CONTRACTOR'S DDECLARATION
License Class Lic. # 73 83
Contractor 01)ff_kAAqp 6.9- -1 1 p f3 e~ L> 7/3, /s-
1 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
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. 7
Signature A Date ! ��
❑ 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).
1 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, 1 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
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
REMOVE/REPLACE (3) ANTENNAS; R/R (3) EQUIPMENT
CABINETS WITH (2); INSTALL GPS ANTENNA; ADD (3)
RRU UNITS.
Sq. Ft Floor Area: I Valuation: $5000
APN Number: 36901065.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPE TIO .
Issued by:� C� ate:a3 6,
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
1 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 1 use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:��' r Date: % 1
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 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014 -3255
(408) 777 -3228 • FAX (408) 777 -3333 • buildingna.cupertino.org
1C- �UPERTINO r-� I-I
1 I NFW Co NSTRIiCTION 1 1 ADDITION I I ALTFRATION / Ti 1 1 RFVISinN / IOFFFRRFD
!Dep
ORIGINAL PERMIT # I-A 4 44v�
PROJECT ADDRESS I,� V ✓O I1� I, /
APN N '
OWNERNAME Ch cave t? eom K
PHONEI�U �� E -MAIL
STREET ADDRESS I �1, n d N /�J f I Aj rya
1e' r 1 ! 1/I
CITY, STATE, ZIP r c � TFAX
CONTACT NAME I
l a
I
PHON
/) n
E -MAIL 1 Q
STREETADDRESSf
l� i "nf
CIjoy -ATE, ZIP y� & 47 5
FAX
❑ OWNER ❑ OWNER- BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
LICENSE NUMBER
LICENSE TYPE
BUS LIC #
COMPANY NAME
E -MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS LIC N
COMPANY N A a g
E -MAIL
FAX
STREET DDRESS
e, va 0 r - Stc.
CTTY, STATE, ZIP
PHON
(�.
DESCRIPTION OF WORK y, / ^'
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
USE
TYPE
p> -)
P '�f
�.
VALUATION (S)
EXISTG
AREA
NEW FLOOR
AREA
DEMO
AREA
TOTAL
NET AREA
1
_
BATHROOM
KITCHEN
OTHER
REMODEL AREA
REMODEL AREA
REMODEL AREA
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
[] ATTACH
_
,.... ,
# DWELLING UNITS'
IS A SECOND UNIT ❑ YES
SECOND STORY ❑YES
BEING ADDED? ❑ NO
ADDITION? ❑ NO
PRE - APPLICATION []YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES
RECEIVED B -
TOTA ALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ❑ NO
Q G O
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. I 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 g construction. I uthor, e resentatives of Cupertino to enter the above-identified property for inspection purposes
Date: 2
Signature of Applicant/Ager
SUPPLEMENTAL INF RMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER - THE - COUNTER
BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
❑ EXPRESS
PLANNING PLAN REVIEW
Commercial Bldgs: Provide a completed Hazardous Materials Disclosure
I STANDARD
❑ PUBLIC WORKS
_
form if any Hazardous Materials are being used as part of this project.
❑ LARGE
❑ FIRE DEPT
Copy of Planning Approval Letter or Meeting with Planning prior to
❑ MAJOR
❑ SANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
BldgApp_ 2011.doc revised 06121111
1 loth
s
FM_7 CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
imADDRESS:
10050 N De Anza Blvd
DATE: 03/02/2015
REVIEWED BY: Sean
MISC ITEMS
APN:
BP #:
'VALUATION:
1$5,000
'°PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Addition / Repair
PRIMARY
USE Commercial Building
Civil / Religious activities
in BQ zone? � Yes • No
PENTAMATION 1 GENCOM
PERMIT TYPE:
WORK
Remove /re lace 3 antennas; R/R 3 equipment cabinets with 2 • install GPS antenna; add 3 RRU
SCOPE
units. (Permit to replace expired permit 12110143)
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 based on the Dreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 11 -053 Eff. 7,,T "Q
FEE
QTY /FEE
MISC ITEMS
Plan Check Fee: Hourly Only? 0 Yes (F) No
$0.00
2 hours Plan Check, Hourly
$286.00 ISTPLNCx
Suppl. PC Fee: Q Reg. Q OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Feele) Reg. Q OT
F0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: IBCONSTAXC
$0.00
0
0
Work Without Permit? Yes (E) No
$0.00
Advanced Planning Fee:
$0.00
Select a Non - Residential
Building or Structure
Q
0
Strongi Motion Fee: IBSEISMICO
$1.40
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
SUBTOTALS:
$2.40
$286.00
TOTAL FEE:
$288.40
Revised: 02/14/2015