B-2016-1425 PERMIT, APP, FEE EST, SUB CONT LISTCITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2016-1425
10555 MARYAVE CUPERTINO, CA 95014-1322 (326 06 052)
(HERCA TELECOMM
SERVICES INC)
PERRIS, CA 92570
OWNER'S NAME: CUPERTINO CITY OF
DATE ISSUED: 02/24/2016
OWNER'S PHONE: 408-777-3269
PHONE NO: 9519405941
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class A. B. C10 Lic. #886274
Contractor( HERCATELECOMM SERVICES INC ) Date 2124/2016
X BLDG —ELECT _PLUMB
MECH RESIDENTIAL X COMMERCIAL
I hereby affirm Hurt I am licensed ender the provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in fell force and effect.
JOB DESCRIPTION:
DEMO (E) 51' MONOPOLE; SPRINT/NEXTEL SHELTER; EQUIPMENT
I hereby affirm under penalty of perjury one of the following two declarations:
PADS AND RESTORE GRADE SURFACE AT CUPERTINO PUBLIC
1. 1 have and will maintain a certificate of consent to self -insure for Worker's
WORKS SERVICE CENTER
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of (he work for which this permit is issued.
z. I have and will maintain Workers Compensation Insurance, as provided for
by Section 3700 of the Labor Code, for die performance of the work for which
Sq. Ft Floor Area:
Valuation: $30000.00
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
APN Number:
Occupancy Type:
ordinances and state laws relating to building construction, and hereby
326 06 052
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
PERMIT EXPIRES IF WORT{ IS NOT STARTED
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 with all non -point source regulations per the Cupertino Municipal
180 DAYS FROM LAST CALLED INSPECTION.
Code, Section 9.18.
Issued O'SULLIVAN .(j �;LO ju r I`�,��
Signature Date 2/24l2016
Date: 2/24YLOlb I . "'t.J�'�
/24 2016
OWNER -BUILDER DECLARATION
RE -ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of the
All roofs shall be inspected prior to any roofing material being installed. If a roof is
following nvo reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1. 1, as owner of the property, or my employees with wages as their sole
inspection.
compensation, will do the work, and the structure is not intended or offered
for sale (Sce.7044, Business & Professions Code)
Signature ofApplicank
2. 1, as owner of the property, am exclusively contracting with licensed
Date: 2 2 2 1
contractors to constructthe project (Soc.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three declarations:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. Ihave and will mountain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued.
I have read the hazardous materials requirements under Chapter 6.95 of the
z. I have and will maintain Worker's Compensation Insurance, as provided for
California Health & Safety Cede, Sections 25505, 25533, and 25534, I will
by Section 3700 of the Labor Code, for the performance of the work for which
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
this permit is issued.
Health & Safety Code, Section 25532(a) should 1 store or haudle brain dons
e. I certify that in the performance of the work for which (ties permit is issued, I
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the
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
Worker's Compensation haws of California, If, after snaking this certificate of
the Health & Safety Code, Sections 25 5,- 5533, and 25534.
exemption, I became subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
Owner authorized agent:
be deemed revoked.
Date: 2124/2016
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
correct. I agree to comply with all city and county ordinances and state laws
of work's for which this permit is issued (Sec. 3097, Civ C.)
relating to building construction, and hereby authorize representatives of this city
Lender's Name
to enter upon the above mentioned property for inspection purposes. (We) agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
Judgments, costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally, the applicant
ARCHITECT'S DECLARATION
understands and will comply with all non -point source regulations per the
I understand my plans shall be used as public records.
Cupertino Municipal Code, Section 9.18.
Licensed
Signature Date 2/2412016
Professional
CITY OF CUPERTINO b@016- 11
FEE ESTIMATOR - BUILDING DIVISION
FAADDRESS:
10555 MARY AVE DATE: 02/24/2016
APN: 326 06 052 BP#:
REVIEWED BY: PAUL
"VALUATION: $30,000
"PERMIT TYPE: Building Permit
PLANCHECI{TYPE: Addition
PRIMARY SFD or Duplex
USE:
PENTAMATION 1 GENRES
PERMIT TYPE:
woRi{
DEMO E 51- MONOPOLE' SPRINT/NEXTEL SHELTER' EQUIPMENT PADS AND RESTORE
SCOPE
GRADE SURFACE AT CUPERTINO PUBLIC WORKS SERVICE CENTER
P T 'm f heck
El _ s ',"an f'/Y'a :A
.'3 P e' 31 t'en,
d"3t i. erm^ hce
tPh, '.ilc.'i_ "asp
�I r i t('-iA?tNn.
Fat , .:'. IM,,.
12h fav" 1"�jf'f
I
NOTE: This estimate does not incladefees due to other Departments (i.e. Planning, Public Works, Fire, Snaitmy Sewer District, School
District, etc.). These fees are based on the nrelimomry information available and are only an o_etiomty_ Contort the Dent fnr adda'1 iafa.
FEE ITEMS (Fee Resolution 11-053 Fff. 711113
FEE
QTY/FEE
___ ______-----
MISC ITEMS
Plan Check Fee: Hourly only? ® Yes Q No
$0.00
0 hours
$143.00
Plan Check, Hourly
ISTPLNCK
Suppl. PC Fee: (D Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee: Hourly Only? ® Yes (E) No
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
0,0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
C:2rastraactiara T<r:�r
. ,,(ulnrm"'A: v Fee:
G
Work Without Permit? ® Yes (2) No
KOO
Advanced Planning Pee:
$0.00
Select a Non -Residential 8
Building or Structure
T nivel 0o( a n,,waat;=ire
St•on r Motion Fee: BSEISMIC2
$3.90
1.0 hrs
$143.00
Inspections
1ST/NSP Inspection, Ho
H 1
Brde Stds Commission Fee; 113CBSC
$2.00
SURTO`a'AL§:
$5.901
$286.001
TOTAL. F
:.
EEf!
$291.90
Revis d:
01/01/2016
KPERTINO 1
NEW CONSTRUCTION
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
�t.
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 /t 116 I L
(408) 777-3228 • FAX (408) 777-3333 • bull dincCa cupert!no.org v�
❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROTECT ADDRESS SJ J Y
APN H I b- V V• D r-
OWNERNAME
PHONE E-MAIL
STREET ADDRESS CITY, STATE, ZIP J V 1 1
FAX
CONTACT NAME
�G
PHON
�I$1 °t
MAI
0
ova
-(w
PG .Ccs I! �IPc
STREET ADDRESS
CITY, STATE, ZIP
FAX
,.,{/
❑ owNaR ElOWN'ER-BUILDER ❑ 5 OWNERAGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTORNAME IVr I^��
LICENSE NUMBER
LICENSE LI�C,/E�NAStE TYPE„W. G/D
BUS. LICg
COMPANYNAME P( � nC
1 C
E-MAIL SD�VVi„er .teiP(-UI/ rr•co r/I
Yi 'C• CL
��1 �l�D•J
STREET ADDRESS
1£s61K S1
CITY, STATE, ZIP
Penis
PHONE
(�sr)�yp.syS"8
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC k
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
fC�,nrt ��+6 GI`
1
I^'v
e Nod • I r 61 Cf -ytd o4 5- -to Pe mooi&l.
EXISTING USE
PROPOSEDUSE
CONSTR, TYPE
:STORIES
USE
TYPE
OCC.
SQ.FT.
VALUATION (S)
EMSTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN OTHER
REMODELAREA
REMODELAREA REMODEL AREA
PORCH AREA DECK AREA TOTALDECIOTORCHATCA
GARAOEAREA: LJDFTACH
❑ATTACH
9DWELLINGUNITS:
IS A SECOND UNIT ❑YES
SECONDSTORY []YES
BEING ADDED? []NO
ADDITION? ❑NO
PRE -APPLICATION ❑YES IF YES, PROVIDE COPY OF
IS THE BLDG AN [I YES
IVEP.BY - - t
TOTAL VALUATION:
PLANNINGAPPLN ❑NO PLANNING APPROVAL LETTER
EICHLERHOME? ❑NO
By my signature below, I certify to each of the following: I am the property owner or authori d 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 diu o ystmct' n. I authorize repre entatives of Cupertino to enter the aboov-identi redd property for inspection purposes.
Signature of Applicant/Agent: Date: 2�2y),�/
SUPPLEMENTAL INFORMATION REQUIRED
e ;• PI:{N cHccx TYPE
- YRouTINc SLIP
New SFD or Multifamily dwellings: Apply for demolition permit for
ov Eg rxE cotnrenc
BUILDt�egLa� REv IEar{.F�?
existing building(s). Demolition permit is required prior to issuance of building
i1
permit for new building.
❑ ECPREss
PLA NING'PLAN REY'IE\;
_ Colmuercial Bldgs: Provide a completed Hazardous Materials Disclosure
❑ sTA.�nARD
PUBLIC RORRS
fonu ifany Hazardous Materials are being used as part of this project.
❑
'1]
LAncE -
PIKE DEPr
_ Copy of Plarming Approval Letter or Meeting with Planning prior to
❑
❑ §EIa
submittal of Building Permit application.
NLsaoE
sA_'\IrAxYERD1sTIucT
Q E\\IRONMENTALHEALTH-
Bld Ayp_2011. doc revised 06121111
Building Department
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax:408-777-3333
JOB ADDRESS:(()US-PERMIT
# R O I -! q-
OWNER'SNAME: LitQf
,) $rj1yj
PHONE#
GENERAL CONTRACTOR:
krco' TZe1$CojrA62
BUSINESS LICENSE # Z 71l
ADDRESS: SOIL) V
ftrfjS
CITY/ZIPCODE: hE✓Y7 - &A `i 7o
*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: T Sr /Z / /�(2
Signature Date
Please check applicable 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
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature
Date