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B-2016-2780i CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2780 10655 MARYAVE CUPERTINO, CA 95014-1355 (326 06 050) C B A SITE SERVICES INC OAKLEY, CA 94561 OWNER'S NAME: CUPERTINO LOC-N-STOR LL DATE ISSUED: 09/22/2016 OWNER'S PHONE: 408-252-7867 PHONE NO: (925) 754-7633 LICENSED CONT ACTOR'S DECT ARATTON BUILDING PERMIT INFO: License Class ELECTRICAL Lic. #455726 Contractor C B A SITE SERVICES INC Date 1 X BLDG _ ELECT _PLUMB I hereby affirm that I am licensed under the of Chapter 9 (commencing _ MECH _ RESIDENTIAL X COMMERCIAL provisions with Section 7000) of Division 3 of the Business &Professions Code and that my license is in full force and effect. JOB DESCRIPTION: (R) 3 ANTENNAS; REMOVE 1 CABINET; INSTALL 1 (1) FIF RACK I hereby affirm under penalty of perjury one of the following two declarations: i. 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 t 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: $25000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above APN Number: Occupancy Type: information is correct.] agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize 326 06 050 A (Tenant Improvements) 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino! Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature , Date 9/22/2016 Issued by: Abby Ayende Date: 09/22/2016 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is 1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sec.7044, Business & Professions Code) 2. I, as owner of the property, atm exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 9/22/2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1. 1 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. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this : California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(a) should I store or handle hazardous shall not employ any person in any manner So as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If, after making this certificate of will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. j O er or authorized agent: / `f Date: 9/22/2016 APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and Thereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the. City of Cupertino against liabilities, judgments, costs, and,expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additiqnally, the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. I understand my plans shall be used as public records. Licensed Signature Date 9/22/2016 Professional