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B-2016-1580CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-1580 10110 CALIFORNIA OAK WAY CUPERTINO, CA 95014 (342 12 030) WALKER CELLULAR INC ROCKLIN, CA 95765 OWNER'S NAME: PACIFIC GAS AND ELECTRIC CO OWNER'S PHONE: 415-989-1102 LICENSED CONTRACTOR'S DECLARATION License Class B. C-7. C-10. Lic. #954113 Contractor WALKER CELLULAR INC Date 11/30/2016 I 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: r. 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 DATE ISSUED: 05/24/2016 PHONE NO: (916) 259-2785 PERMIT INFO: BLDG —ELECT —PLUMB MECH _ RESIDENTIAL X COMMERCIAL JOB DESCRIPTION: INSTALL 3 (N) ANTENNAS, 3 (N) RRVS, REPLACE AND UPGRADE (E) CIRCUIT BREAKER 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. Sq. Ft Floor Area: Valuation: $20000.00 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 5/24/2016 OWNER -BUILDER DF ARA I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 1. I, 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) 2. I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 1. 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. 2. 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. s. 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, I 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. APN Number: Occupancy Type: 342 12 030 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LIACA INSPECTION. Issued by: Alex Vallelunea i r Date: 05/24/2016 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: 5/24/2016 ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I 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(x) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous 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 the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: 5/24/2016 CONST UCTT L T A E Y 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 Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Date 5/24/2016 Professional CUPERTINO F1 NF W rOMSTR i Tr-rTOW 5WZA CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 90300 TORRE AVENUE • CUPERTINO, CA 95014-3265 (408) ))1 n777-3228 - FAX (408) 777-3333 • building@,cugertino.ora 2 _ 2-0 / 1f� ATtITTAXf M AT T17D A. TnM I -T 17 TI—TI�lllilT) TOL'nnnT`T.� jam. [� PROTECT ADDRE 0 C \b��L APN 0.1011 - OWNERNAME PHONE E,. -�MAI�L STREET ADDRESS\.,, y�`�T� CITY, STATE,ZIPC1 1 l FAX CONTACT NAME /��1 { �[t � d �n, Qg �y � PHONE (• pq a (�;.cr��P�i""'� �,l f e � e w { � �j E-MAIL /��I* �-t.C:.�I�TC✓�S ��/ �' lAC/�t�:S STREET ADDRESS �C<! C c3tJ� A�Y, STA C'L�'V L,Lt��' FAX O OWNER CI OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR 11 CONTRACTOR AGENT ❑ ARCHITECT © ENGINEER 0 DEVELOPER TENANT CONTRACTORNAME b LICENSE NUMBER LICENSE TYPE EUS, LIC COMPANY NAME E-MAIL _ FAX STREET ADDRESS. CITY, STATE, zip PHONE ARCHITECVENGINEFR NAME LICENSE NUMBER + p� EUS. LIC # COMPANYNAME_/1t( E-MAIL FAX STREET ADDRESS e^}Z7.' %v CITY,STATE,ZIP J l,ri3 (x Y or DESCRIPTION OF WORK { /+ EXISTING USE PROPOSED USE CONSTR. �✓' / TYPE # STORIES USE TYPE OCC. SQ.FT. VALUATION {$) G AREA AREA NEW FLOOR AREA DEMO AREA TOTAL NL•T AREA _ BATHROOM I - KITCHEN OTHER RFMODELARRA REMODEL AREA REMODEL AREA PORCHAREA DECK AREA TOTALDECKlPORm AREA GARAGEARF.A: DF.TAf, ATTACH I # DWELLING, UMTS: IS A SECOND UNIT ❑YES SECONDSTORY QYEs BRING ADDED? JaNO AUDITION? 1MINO PRE -APPLICATION YHs IIT YI±S, PROVIDF: COPY OF ISTHEELDGAN ®YES ,D TOTAL VALUATION: PLANNING APPLE NO PLANNING APPROVAL LETTER EICHLERHOME? p'NO t 'x 4 oo By my signature below, I certify to each of the following: I am the property owner ar abi Lori d agent t4 act on the property owner's behalf. I have read this application and the information l have provided is connect. I have read the Description of Work a it is accurate. I agree to comply with all applicable local ordinances and state laws rolating to uilding onstrru I authorize representatives of Cupertino to enter the above -identified) property for inspection purposes. jc�tionnn. Signature of Applicant/Agent:I L V IL`y� Date: d SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP El OVER-THE-COUNTER puvrEtt © 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. E EXPRESS E PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure CI STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. LARGE E IrIgE DEPT _ Copy of Planning Approval Letter. or Meeting with Planning prior to ❑ MAJOR ❑ SANITARY SEWERDISTRICT submittal 'of Builduig Permit application. E ENVIRONMENTAL HEALTH BldgApp_2011.doe revised ©6121/11