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13090137 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19050 PRUNERIDGE AVE CONTRACTOR-T L Tn BE PERMIT NO: 13090137 QED OWNER'S NAME: CAMPUS HOLDINGS INC i DATE ISSUED: 10/07/2013 OWNER'S PHONE: 4089748821 CC'I �rI`�li rirC�1" l "� PHONE NO: 16, ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lic.# U �� APPLE-INSTALL A TEMPORARY UNMANNED WIRELESS / TELECOM FACILITY. Contractor Date 10 7 1 hereby affirm that 1 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. 1 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: Valuation:$5000 11 have and will maintain Worker's Compensation Insurance,as provided for by ction 3700 of the Labor Code,for the performance of the work for which this APN Number:31606033.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN I�80 DA YS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter D4 YS the above mentioned property for inspection purposes. (We)agree to save 180 DAY F M LAST CALLED INSPE TI N. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the /� U granting of this permit. Additionally,the applicant understands and will comply Issued by: 1 Date: with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 21 ? RE-ROOFS: Signature Date 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. ❑ OWNER-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, wil I do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 2550..5,,,2255,3,3,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this /� Date /6/y/ / permit is issued. Owner or authorized agent: 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I 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 CERTIFICATION Lender's Address 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, 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 CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT-BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO. CA 95014-3255 !408)7177-3228-FAX(408)777-3333 CUPERTINO 0 NEW CONSTRUCTION ADDII-ION ALTE RAI-ION -17 REVISION/DEFERRED ORIGINAL PERMIT# PROJECT NDDRE.1,S IX9APN 0 05- 0 Pram �:ia L 314, 3 'AW -9 OWNER ,-0 A, fird I STREET ADDRESS rip FAX 1A A4 5-ffwc r/A 0 95-0 CONTACT NAME.. PW) E-MAIL 0A1 0 dO rAt4 11 OWNER 0 OWNIR-BUILMR q0 OWNER AGENT 0 cosrnAcTok 11 ca,4i-RACTOR A(W.Nr 0 ARCHM.0 13 E-11GINE4,1t 0 DEVELOPER 11 TENANT CONTRACTOR NAME, LICENSF NUMBER LICENSE TYPE MIS LK 0 COMPANY NAW. E-MAIL fAx STREET ADDRESS CITY,STATE,ZIP PROW CWTECT,V4G1NEER NAME LICENSE NUMBER HUS LIC,# A1W OMPAtV1, NAME E-MALL FAX lap- V, FT ADDRESS C&SST'ATE,ZIP MQ11E r DESCRIPTICNJ .4 If/it WOR 00P W-gid 1'&1AJe'fA Ira Ar I rA eJ4. 4 Cleah-trA #1v a,%,;q (,,oees.) &s&qi-ala tmewxw.(1,- agewhot4dLC-4 Ptgo, Cl.) 'e EXISTING USE MOMSED USE FS r 0 i't N,4 'T (S) IWI f is V'-a USE TYPE (XIC SQ F VAH,'A11C1N LXSTCI NE**m(X)R I DEMO TOTAI AREA AREA J�(AREA NET AREA s-C too JJW. BATHROOM KfTCHEN01MR REMODEL.AREA REMODELAREA RENDMI AREA piWeVIMR—EA WK AREA I rOTA1.DECKII ORCH AREA GARAGE AREA H DETACH XrrAC. ` 0 DWELLING UNITS -ISAiW*DtMiffoR 06`-s- OWAING&DWD? MO ADVIT11ON? W) PRE-APPLICATION IF YES.PROVIDF COPY OF LS TIM BLDG AN, V' RE. TOTAL VALUATJOW-� PLANNING APPI,# RNX PLA,"MG APPROVAL I-UTTER 11:11CMER ROME I No sove-, By my signature below,I unify to each of the following: I am the property ownet or authorized agent to act on the property owner's behalf I have read this application WW the mformation I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordlinarim and state laws relating to building construcatin. I authorize representatives of'Cupertino to enter the above-identified property for inspection purposes Signature ol'Applicant/Ngent. Date.-1-zRe-13 — SUPPLEMWTAL INFORMATION REQUIRED KAN CHECK TVpK RMTMSLtp New SFD or Multifamily dwellings: Apply for demolition permit for 0 0VEWTHFA'MN-l%R ❑ BUILDING PLAN REVIEW exCitingbuilding(s). Demolition permit is required prior to issuance of building permit for new building. El lr-xpltm D PlANNtNG PLAN REVWW Commercial Bldgs: Prov ide a completed Hazardous Materials Disclosure EJ STANDARD 13 FUKKWOM Form if any flazArdous Materials are being used as peal of this project. 0 LARGE 0 nikE DM —Copy of Planning Approval letter Or Meeting with Planning prior to 11 H&M 0 SAWARY UWFR WtRWT submittalof Building Permit application. I 1 0 ENV1#1tWWXTAL IWALT-11 HldgApp.201 Ld"revised 06/21.,11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 19050 Pruneridge ave DATE: 09/18/2013 REVIEWED BY: Mendez APN: BP#: /—'M Y01,3 VALUATION: 1$5,000 'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION -FELECOMFAC USE: PERMIT TYPE: WORK install a temporary unmanned wireless telecom facility SCOPE ; LJ "j, f�i /);ar j.i, �)7 S'� Li NOTE.This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc). These ees are based on the grelimina information available and are on an estimate Contact the Dept-for addn'l info. FEE ITEMS(Fee Resolution 11-053 E ' 711111 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: 0 Reg. 0 OT FO.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-0 Reg. OT FO,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 0 Work Without Permit? Yes (j) No $0.00 0 Advanced Planning Fee: $0.00 F1 # Antenna-Telecom Facility f�zt el 00Fr �.,: $1,112.00 IgNTCELFRE Cellular,Free-Standing ©� Strong Motion Fee: IBSEISMICO $1.05 Select an Administrative Item Bldy, Stds Commission Fee: IBCBSC $1.00 SURT'OTALS $2.051$1,112.001 TOTAL FEE $1,114.05 Revised: 08/01/2013