15080207CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10101 N DE ANZA BLVD
CONTRACTOR:; PERMIT NO. 15080207
OWNER'S NAME: WATERDRAGON 289 LLC
DATE ISSUED: 10/16/2015
OWNER'S PHONE: 4082528450
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1..t� fi C PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPT ON: RESIDENTIAL ❑ COMMERCIAL ❑
AT&T - REPLACE1112 (E) ANTENNA'S ON (E) CELL SITE
License Class Lie. #
LOCATION:
Contractor Date/,O
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:
Sq. Ft Floor Area,
Valuation: $25000
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
APN Number: 3234071.00
Occupancy Type:
performance of the work for which this permit is issued.
2`®lp"have and will maintain Worker's Compensation Insurance, as provided for by
i
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
PERMITiEXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is
180 DAYS FROM LAST CALLED INSPECT ON.
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 for
above mentioned property inspection purposes. (We) agree to save
Issued by: Date:
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 regu ions per the Cupertino Municipal Code, Section 9.18.
RE-ROOFS:
All roofs shall be i4spected 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: _
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
t. 1, 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
j HAZARDOUS MATERIALS DISCLOSURE
sale (Sec.7044, Business & Professions Code)
I have read the had ardous materials requirements under Chapter 6.95 of the
2. I, as owner of the property, am exclusively contracting with licensed contractors to
California Health (& Safety Code, Sections 25505, 25533, and 25534. I will maintain
construct the project (Sec.7044, Business & Professions Code).
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations:
t I have and will maintain a Certificate Consent to for Worker's
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
of self-insure
Compensation, as provided for by Section 3700 of the Labor Code, for the
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Code,
performance of the work for which this permit is issued.
Health & Safety Sections 25505, 25533, and 25534.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Owne r autho ize agent:
Section 3700 of the Labor Code, for the performance of the work for which this
Date
permit is issued.
3. I certify that in the performance of the work for which this permit is issued, I shall
CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
I hereby affirm that there is a construction lending agency for the performance of work's
Compensation laws of California. If, after making this certificate of exemption, I
for which this permit is issued (Sec. 3097, Civ C.)
become subject to the Worker's Compensation provisions of the Labor Code, I
Lender`s Name I
must forthwith comply with such provisions or this permit shall be deemed
revoked.
Lender's Address;
APPLICANT CERTIFICATION
ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is
I understand my plans shall be used as public records.
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
Licensed Professional
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
j
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.
i
Signature Date
j
CITY OF CUPERTIN, 0
FVF, F.qTIM A Tn11? - 'nl[TTF .'nlrT%Tt-1 "TX71Q1rnXT
-
IlaADDRESS: 10101 N DE ANZA BLVD
ATE: 08/28/2016
REVIEWED BY: MELISSA
APN: 326 34 071
BP#.VALUATION:
1$25,000 sl
*PERMIT TYPE: Building Permit
PLAN CHECK TYk: Tenant Improvement
PRIMARY
USE: Commercial Building
Su 1. PC Fee: •(j) Reg. 0 OTF
o-. -o
PENTAMATION
TELECOMFAC
$0.00
PME Plan Check:
PERMIT TYPE:
WORK
REPLACE 12 (E) ANTENNA'S ONE
CELL SITE
SCOPE
$0.00
Suppl. Insp. Fee: (j) Reg. 0 OT
}tech.T--ech. Plan Check M -
C 7"
Ian lecic Elee. Man Cheek
3•tec lt. 1'erfnit Fee: Plumb, 1'ej-1nit 17ee: El, -u. Peo-nit Fee:
F
Other Phan bInsi-). F-1 11 01her Flee, hISP
Much. hzs,)Fe": I'lumb, IrsD, Fee:
Ek /Asp. Fee:
NOTE. This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
M.Wript- Ptr I Thoep faac firo h"cod n" fha nroli—i""ry infnvmnfin" "iy"Unbla and "Ira n"h) a" actimiyto 1-noit"rt tho Dont fhr iyddil 11 i"fn-
FEE ITEMS (Fee Resolution 1.7-053 Eff. 7/1/13,FEE
QTY/FEE
F—MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Su 1. PC Fee: •(j) Reg. 0 OTF
o-. -o
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee: (j) Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax:
Adnfinisi,-f 'ive F
it -W:
0
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
#
$1,145.00=IANTCELAYT
Antenna - Telecom Facility
I Cellular, Attached to Bldg—0
E)
Travel.Documenialion P-ees:
Strong Motion Fee:
IBSEISMICO
$7.00
Select an Administrative Item
Bldg Stds Commission Fee: 1BCBSC
$1.00
STQTALS x
$8.001$1,145.0',0
$1,1153-00
Revised: 07/02/2015
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10101 N DE ANZA BLVD
DATE: 08/28/2015
REVIEWED BY: MELISSA
APN: 326 34 071
BP#: '
"VALUATION: 1$25,000
PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Tenant Improvement
PRIMARY
USE: Commercial Building
PENTAMATION
PERMIT TYPE: TELECOMFA
WORK
REPLACE 12 E ANTENNA'S ONE CELL SITE
SCOPE
i
illech. Plan Check
Phrntb. Plan Check
Elec. Plan Check
;L1ech. 1'errnit F'ee:
Plumb. Permit Fee:
Elec. Permit Fee:
Other illech. Insp.
Other Plumb Insp.
E.
Other Dec. Insp.
Hech. /lisp. Fee:
Phimb. Insp. Fee;
Elea Insp. Fee:
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Dept for addn'1 info:
FEE ITEMS (Fee Resolution 11-053 E . 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: (•) Reg. 0 OT
FO,0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. 0
OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tar:
Actnrinistrative Fee:
0
G
Work Without Permit? 0 Yes (F) No
$0.00
Advanced Planning Fee:
$0.00
1� #
$1,145.00
Antenna - Telecom Facility G
IANTCELATT Cellular, Attached to Bldg C
Travel Docurnentalion Fees:
Strong Motion Fee:
IBSEISMICO
$7.00
Select an Administrative Item
Blda Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:.
$8.00
$1,145.00
TOTAL FEE:
$1,153.00
Revised: 07/02/2015