15070118CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: 15070118
10655 MARY AVE CUPERTINO CA 55014 (326 06 050)
QUALITY TELECOM
CONSULTANTS INC
LOONUS, CA 95650
OWNER'S NAME:
DATE ISSUED: 10/11/2016
OWNER'S PHONE:
PHONE NO: (
LICENSED CD-N-TRACTORIS DECLARATION
BUILDING PERMIT INFO:
License Class A. B. C10. C51 & Coo Lic. # 14 59
Contractor QUALITY TELEC_QM CONSULTANT$ lNC Date 11130/2018
—BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter S (commencing
_ MECH _ RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
VERIZON: SWAP (6) PANEL ANTENNAS; REMOVE (1) RET
CABLE; INSTALL (3) DIPLEXERS, (3) RRU'S, (1) SURGE
1. I have and will maintain a certificate of consent to self -insure for Worker's
SUPPRESSION UNIT, AND (1) HYBRID CABLE.
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.
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
APN Number:
Occupancy Type:
and state laws relating to building construction, and hereby authorize
32606050
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 CAL SPECTION.
t
Signature��- Date 10/11/2016
Issued LYS
Date: 11/2016
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. 1, 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. 1, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 10/11/2016
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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
HAZARDOUS MATERIALS DISCLOSURE
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
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
permit is issued.
Health & Safety Code, Section 25532(a) should I store or handle hazardous
3. 1 certify that in the performance of the work for which this 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
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.
Owner or authorized agent:
APPLICAlNT CERTIFICATION
Date: 10/11/2016
t• v LEN AGENCY
I certify that I have read this application and state that the above information is
-DING
construction lending agency for the performance
ere is a construction
I hereby affirm that there is
correct. I agree to comply with all city and county ordinances and state laws
i
of for which this permit is issued {Sec. 3097, Civ C.)
relating to building construction, and hereby authorizes representatives of this city
Lender's
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 understands
ARC'HITECT'S DECLARA'T'ION
and will comply with all non -point source regulations per the Cupertino Municipal
I understand my plans shall be used as public records.
Code, Section 9.18.
Licensed
Signature —__Date 10111/2016
Professional
SITESAFE
RF COMPLIANCE EXPERTS
A BusINFs5 OF FDH VELOCITEL
RF EMISSIONS COMPLIANCE REPORT
Crown Castle on behalf of Verizon Wireless
Crown Castle BU: 815035
Crown Castle Site Name: Highway 280/85 Rev.
Verizon Wireless Application ID: 285925
10655 Mary Avenue
Cupertino, CA
8/27/2015
Registration Expires December 31, 2016
Report Status:
Matthew J Butcher
Registered Professional Engineer
State of California License E 18612
Prepared By:
Sitesafe, Inc.
200 North Glebe Road, Suite 1000 Arlington, VA 22203 Voice 703-276-1100
Fax 703-276-1169
Engineering Statement in Re:
Electromagnetic Energy Analysis
Verizon Wireless
Cupertino, CA
My signature on the cover of this document indicates:
That I am registered as a Professional Engineer in the jurisdiction indicated; and
That I have extensive professional experience in the wireless communications engineering
industry; and
That I am an employee of Sitesafe, Inc. in Arlington, Virginia; and
That I am thoroughly familiar with the Rules and Regulations of the Federal Communications
Commission ("the FCC" and "the FCC Rules") both in general and specifically as they apply to
the FCC's Guidelines for Human Exposure to Radiofrequency Electromagnetic Fields; and
That the technical information serving as the basis for this report was supplied by Verizon
Wireless (See attached Site Summary and Carrier documents), and that Verizon Wireless'
installations involve communications equipment, antennas and associated technical equipment at
a location referred to as the "Highway 280/85 Rev." ("the site"); and
That Verizon Wireless proposes to operate at the site with transmit antennas listed in the carrier
summary and with a maximum effective radiated power as specified by Verizon Wireless and
shown on the worksheet, and that worst-case 100% duty cycle have been assumed; and
That this analysis has been performed with the assumption that the ground immediately
surrounding the tower is primarily flat or falling; and
That at this time, the FCC requires that certain licensees address specific levels of radio-
frequency energy to which workers or members of the public might possibly be exposed (at
1.1307(b) of the FCC Rules); and
That such consideration of possible exposure of humans to radio-frequency radiation must utilize
the standards set by the FCC, which is the Federal Agency having jurisdiction over
communications facilities; and
That the FCC rules define two tiers of permissible exposure guidelines: 1) "uncontrolled
environments," defined as situations in which persons may not be aware of (the "general public"),
or may not be able to control their exposure to a transmission facility; and (2) "controlled
environments," which defines situations in which persons are aware of their potential for
exposure (industry personnel); and
That this statement specifically addresses the uncontrolled environment (which is more
conservative than the controlled environment) and the limit set forth in the FCC rules for
licensees of Verizon Wireless' operating frequency as shown on the attached antenna worksheet;
and
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1111113:ESAFED
A eosin [ss or 1.H 1-171 .
That when applying the uncontrolled environment standards, the predicted Maximum Power
Density at two meters above ground level from the proposed Verizon Wireless operation is no
more than 5.681 % of the maximum in any accessible area on the ground and
That it is understood per FCC Guidelines and OET65 Appendix A, that regardless of the existent
radio-frequency environment, only those licenses whose contributions exceed five percent of the
exposure limit pertinent to their operation(s) bear any responsibility for bringing any non-
compliant area(s) into compliance; and
That when applying the uncontrolled environment standards, the cumulative predicted energy
density from the proposed operation is no more than 5.681 % of the maximum in any accessible
area up to two meters above the ground per OET-65; and
That the calculations provided in this report are based on data provided by the client and antenna
pattern data supplied by the antenna manufacturer, in accordance with FCC guidelines listed in
OET-65. Horizontal and vertical antenna patterns are combined for modeling purposes to
accurately reflect the energy two meters above ground level where on -axis energy refers to
maximum energy two meters above the ground along the azimuth of the antenna and where area
energy refers to the maximum energy anywhere two meters above the ground regardless of the
antenna azimuth, accounting for cumulative energy from multiple antennas for the carrier and
frequency range indicated; and
That the Occupational Safety and Health Administration has policies in place which address
worker safety in and around communications sites, thus individual companies will be responsible
for their employees' training regarding Radio Frequency Safety.
In summary, it is stated here that the proposed operation at the site would not result in exposure
of the Public to excessive levels of radio-frequency energy as defined in the FCC Rules and
Regulations, specifically 47 CFR 1.1307 and that Verizon Wireless' proposed operation is
completely compliant.
Finally, it is stated that access to the tower should be restricted to communication industry
professionals, and approved contractor personnel trained in radio-frequency safety; and that the
instant analysis addresses exposure levels at two meters above ground level and does not address
exposure levels on the tower, or in the immediate proximity of the antennas.
2 of 7
SITESAFE
F. BU SI:E5E O" FpN VELOCITEL
Verizon Wireless (Proposed)
Highway 280/85 Rev.
Site Summary
Carrier Area Maximum Percentage MPE
Verizon Wireless (Proposed) 1.594%
Verizon Wireless (Proposed) 3.039%
Verizon Wireless (Proposed) 0.283%
Verizon Wireless (Proposed) 0.766%
Composite Site MPE: 5.681 %
3of7
SITESAFE
c o s ness of FOH vc Baa*ems
Verizon Wireless (Proposed)
Highway 280/85 Rev.
Carrier Summary
Frequency: 1970 MHz
Maximum Permissible Exposure (MPE): 1000 NW/cm^2
Maximum power density at ground level: 15.94002 NW/cm^2
Highest percentage of Maximum Permissible Exposure: 1.594
Antenna Make Model
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
Height Orientation
feet) (degrees true) ERP (We
47 40 2292
47 160 2292
47 280 2292
4of7
On Axis Area
Max Power Max Power
Density Percent of Density Percent of
NW/cm^2) MPE pW/cm"2 MPE
15.727835 1.572783 15.727835 1.572783
15.727835 1.572783 15.727835 1.572783
15.727835 1.572783 15.727835 1.572783
SITESAFE
A B115 f.E55 of SDH VEL--
Verizon Wireless (Proposed)
Highway 280/85 Rev.
Carrier Summary
Frequency: 880 MHz
Maximum Permissible Exposure (MPE): 586.67 NW/cm^2
Maximum power density at ground level: 17.8306 uW/cm^2
Highest percentage of Maximum Permissible Exposure: 3.03931 %
Antenna Make Model
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
Height Orientation
feet) (degrees true) ERP (We
47 40 1446
47 160 1446
47 280 1446
5of7
Area
Max Power Max Power
Density Percent of Density Percent of
NW/cm"2) MPE pW/cm"2 MPE
9.571568 1.631517 10.748494 1.83213
9.829919 1.675554 10.748494 1.83213
9.829919 1.675554 10.748494 1.83213
SITESAFE
F. Bl.'S1h E55 Of SDN VELA CIiEL
Verizon Wireless (Proposed)
Highway 280/85 Rev.
Carrier Summary
Frequency: 2140 MHz
Maximum Permissible Exposure (MPE): 1000 NW/cm^2
Maximum power density at ground level: 2.8252 pW/cm^2
Highest percentage of Maximum Permissible Exposure: 0.28252 %
Antenna Make Model
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
Height Orientation
feet) (degrees true) ERP (W
47 40 501
47 160 501
47 280 501
6of7
On Axis
Max Power Max Power
Density Percent of Density Percent of
NW/cm"2 MPE NW/cm^2) MPE
2.501289 0.250129 2.767913 0.276791
2.501289 0.250129 2.767913 0.276791
2.501288 0.250129 2.767913 0.276791
SITESAFE
t OL Si:E55 OF GDh1 VEI CIrEL
x
Verizon Wireless (Proposed)
Highway 280/85 Rev.
Carrier Summary
Frequency: 751 MHz
Maximum Permissible Exposure (MPE): 500.67 NW/cm^2
Maximum power density at ground level: 3.83341 NW/cm^2
Highest percentage of Maximum Permissible Exposure: 0.76566 %
Antenna Make Model
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
ANDREW SBNHH-1D65B
Height Orientation
feet) (degrees true) ERP (W
47 40 501
47 160 501
47 280 501
7 of 7
On Axis Area
Max Power Max Power
Density Percent of Density Percent of
NW/cm"2) MPE (NW/cm^2) MPE
1.884457 0.37639 3.275503 0.654228
1.884457 0.37639 3.275503 0.654228
1.868436 0.37319 3.275503 0.654228
SITE SAFE