11020075 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:=T0OTHlLL&280 CONTRACTOR:NOR CAL
PERMIT NO:1/020075
COMMUNICATION&
OWNER'S NAME: CALTRANS 5130 FULTON DR STE M
DATE ISSUED:02/18/2011
OWNER'S PHONE: 5102861281 FAiRFIELD,CA 94534
PHONE NO:(707)294-2051
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RIESIDENTIALO COMMERCIAL
License Class_�,� lQO
Lic.k pip 2-1 gj INSTALL OF FiBER MODEM BOX INTO THE LEASE AREA
Contracto OF
Date 1 I AN EXISTING CELL SITE FOR T-MOBILE WEST
I hereby affirm that I am licensed under the provisions of Chapter 9 CORPORATION
(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. Sq.Ft Floor Area:
1 have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$4000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. APN Number. _ e( Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter WITHIN I80.DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
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. Ad ''ovally,the applicant understands and will comply Issued by: Date:
with all non- i - rce gul n er the Cupertino Municipal Code,Section
9.18.
Signature RE-ROOFS:
Date Cl i( 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
OWNER-BUILDER DECLARATION inspection.
I hereby arum that I am exempt from the Contractor's License Law for one of Signature-of Applicant: Date:
the following two reasons:
[,as owner of the property,or my employees with wages as their sole compensation, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec:7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
!hereby affirm under penalty of perjury one of the fallowing three
declarations: maintain compliance with.the Cupertino Municipal Code,Chapter 9.12 and the
i have and will maintain a Certificate ofConsent to self-insure for Worker's Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as def ncd b the Ba Area Air
y y Quality Management District I
performance of the work for which this permit is issued. will maintain compliance`with t er' o n' ipal Code,Chapter 9.12 and
i have and will maintain Worker's Compensation insurance,as provided for by the Health&Safety Code, c ons 5 ,2 5 d 4.
Section 3700 of the Labor Code,for the performance of the work for which this Z +
permit is issued. Owner or authorized ag Date- }
I 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,1 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,t must l hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTiFI!ATION Lender's Address
i certify that 1 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, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date