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12090189 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 23600 VIA ESPLENDOR CONTRACTOR:BROKEN ARROW PERMIT NO: 12090189 COMMUNICATIONS OWNER'S NAME: ROMAN CATHOLIC BISHOP OF SAN JOSE, 8316 CARONA LOOP N E DATE ISSUED:06/10/2013 OWNER'S PHONE: 6509440100 ALBUQUERQUE,NM 87113 PHONE NO:(505)262-2621 66 LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL License Class ' <- 'IU kic.# o9Y 3t{J�l REAR PARKING LOT ALONG THE NORTH EAST ADJACENT TO Contractor Bi2..Gr"C u./ Qk o td/_ Date:)," (fit LO I.? HIGHWAY 280-AT&T CONSTRUCT NEW TELECOM SITE I hereby affirm that I am licensed under the provisions of Chapter 9 TO (commencing with Section 7000)of Division 3 of the Business&Professions INCLUDE ANTENNAS,CABINETS,RETAINING WALL, Code and that my license is in full force and effect. FENCE I 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:$200000 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 APN Number:34254016.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK ISNOT STARTED correct.1 agree to comply with all city and county ordinances and state laws relating WI THI 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DA OM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the /v�/3 granting of this permit. Additionally,the applicant understands and will comply Issued by: Date: Y with all non-point source regu 'ons per the Cupertino Municipal Code,Section 9.18. 1�� RE-ROOFS: Signature Date__iQ 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 I 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 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) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I 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 I 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 25505,25533,and 25534. Section 3700 of the Labor Code,for the performance of the work for which this �, permit is issued. Owner or authorized agent: Date: d' r 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 ARCHF TECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, 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 • CUPERI-1 NO, CA 95014-3255 CUPERTINO (408) 777-3228• FAX (408) 777-3333 • buildingcDcupertino.org 19NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION/Ti ❑ REVISION/DEFERRED ORIGINAL PERMIT# PROJECT ADDRESS Z q 60_0 ®� /� or F�/CJhn� APN 9 3 Li OWNER NAME III F FO 9%) J,M W RA w7 1v+�C NP SA N A TOW 0 HO E-IvtE-11,Po o} 4 --ptO� STREET ADDRESS CITY, STATE,ZIP FAX 23500 \/1A EsputIU0012 c4ghTwO, CA ' ADL CONTACT NAME PHONE 1 1W E-MAIL AKW r.�V1A4f-1 2 36(:5-0227— /A//iJ/"!R `OA2Aan STREET ADD SS CITY,STATE, ZIP AX b .A ackoCa ?moot W1,4c,up C1� 9 �9 0 519- G51Z ❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE ARCHITECT/ENGINEF�[2 NAME-•y,N�/ ,ALL S IQ LICENS NUMBER BUS.LIC# Y o L I U !' D• 2f fo COMPANY NAMEE-MAIL F AX- Pt) GD D� co • N 9 v5 .V -5656 STREET A2DRESS A1 O LI/0 , /VQ ATE,ZIP ys j„0 PHO -/oG�C / DESCRIPTIIOON OF WORK F/ CJ �O 6 A. t✓ I'kAHuL'b r.E b virJG 4 8, 4*J C , NF t�+ rJ/t1D W E©v C61& W,rl L r<0. AJ 4¢pis 4 11NQ1VQ1 ie ONO- f D r-A L-yr TVS ' �J�/2 �l�cf� f Dv/�G Tsi+9s/ (�, /Z R w rJ EXISTING USE PROPOSED USE CONSTR.TYPE k STORIES USE TYPE OCC. SQ.FT. VALUATION(S) EXISTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA BATHROOM KITCHEN OTHER REMODEL AREA REMODEL AREA REMODEL AREA PORCH AREA DECK AREA TOTAL DECKIPORCH AREA GARAGE AREA: DETACH ❑ATTACH #DWELLING UNITS: IS A SECOND UNIT ❑YES SECOND STORY ❑YES BEING ADDED? ❑NO ADDITION? []NO PRE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE BLDG AN ❑YES RECEIVED BY: - TAL VALUATION:(2'()PLANNING APPL# E]NO PLANNLNG APPROVAL LETTER EICHLER HOME? ❑NO rD D i1 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have pro ided is corr e Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to s ctio au riz r entatives of C pertino to enter the ab ve-ide ified property for inspection purposes. Signature of Applicant/Agent: Date: 2� /Zpl SUPPLEMENTAL INFO ON REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVER-THE COUNTERBUC3'm G PLAN REVIEW existing budding(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ���NING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure -STANDARD I PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGEFIRE EPT Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR submittal of Building Permit application. ❑ ENVIRONMENTAL HEALTH BldgApp_201 1.doc revised 06/21/11 Building Department City Of Cupertino 10300 Torre Avenue Cupertino, CA 95014-3255 Telephone: 408777-3228 C U PERT1 N O Pax:408-777-3333 CONTRACTOR/ SUBCONTRACTOR LIST JOB ADDRESS: , A -61S10z71VO4 PERMIT# 1�2 (5 4/ O WNER'S NAME:' ,s,., �� DL,'c PHONE# cS- (0 071 9 �-7 ) GENERAL CONTRACTOR; J3t-oVewv�a�-C'' rys�t_ BUSINESS LICENSE# 3�`P ADDRESS:. �j a�r,Nh o J CITY/zIPCODE; .-�6 U u ER lVel u *Our.municipal.code requires all businesses.worldngin the city to have a City of.Cupertino business license. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO BUSYNESS LICENSE. 1 am not using any subcontractors: Signature Date Please check.applicable subcontractors and complete the following information: ✓ SUBCONTRACTOR BUSINESS NAME ]BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass f Glazing Heating hisulation OP Landscaping I�,�s,,,t G�-i J Q Lathing ! Masonry Painting/Wallpaper Paving ` Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile J �t Owner ontractar Sigia-0trl Date Building Department City Of Cupertino 10300 Torre Avenue Cupertino,CA 95014-3255 Telephone: 408-777-3228 C O P E RT I N O Fax:408-777-3333 CONTRACTOR/SUBCONTRACTOR LIST JOB ADDRESS: ',4 .S' P)✓RN11T# / 6 0 OWNER'S NAME: PHONE# .2(,2_ �,7/ y6p 7 GENERAL CONTRACTOR; II�.a �,,, Ct�vr �—C� nit- BUSINESS LICENSE# -;:e2- ADDRESS: ,K31L ClTX1Z1PQODE' 46u.q'U-fA /UCl *Our municipal code requires all businesses working in the city to have a City of Cupertino business Ii—cense. NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WELL BE SCHEDULED UNTIL THE GENERAL CONTRACTOR AND ALL SUBCONTRACTORS KAVE OBTAINED A CITY OF CUPERTINO BUSINESS LICENSE. I am not using any subcontractors: Signature Date Please cheek.applicable subcontractors and complete the following information: ✓ SUBCONTRACTOR BUSINIES� NAME 13USINESS LICENSE # Cabinets & Millwork Cement Finishing Eleeb�acal Excavation Fencing Flooring/Carpeting Linoleum/Wood Glass/Glazing Heating insulation Landscaping ----- Landscaping �"c.✓.sta� ,C�r s� Lathing Masonry Painting/Wallpaper Paving Plastering ' Plumbing Roofing J E N S E N L, A N o n G A c . Septic Taub Jensen Landscape Services,Inc. Sheet Metal ucen.«i15378S4 Shcet Rock Tile / �2-t Owner ontractor Signa Date CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS: 23005 via esplendor DATE: 0912012012 REVIEWED BY: bob s. APN: BP#: 'VALUATION: 1$200,000 *PERMITTYPE: Building Permit PLANCHECKTYPE: Tenant Improvement PRIMARY Commercial Building PENTAMATION TELECOMFAC USE: PERMIT TYPE: WORK construct new telecom site to include antennas cabinets retaining wall fence enclosure radio units SCOPE surge projectors. Mech.Plan Check Plumb, i`,w ChecF Elec.Plan Check lfe- hA Permit Fee Plumb. Permit Fee: F:lec. Permir Fee. Other Afech.Insp, Other Plumb InspL�j �j Other Elee. Insp. Li AAvh.Insp.Fee: Plumb, In Fp, Feer. Elec.Insp. Fce: NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works, Fire,Sanitary Sewer District,School District,eta). These ees are based on the prelimina information available and are on an estimate Contact the De t or addn7 info. FEE ITEMS (Fee Resolution 11-053 Efr 7/1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 Select a Misc Bldg/Structure Suppl. PC Fee: 0 Reg. 0 OT 0.0 hrs $0.00 or Element of a Building PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-(F) Reg. Q OT 0.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consir action Tax: Administrative Fee: 0 Work Without Permit? Yes (j) No $0.00 0 Advanced Planning Fee: $0.00 1 # Antenna-Telecom Facility Travel Documentation Fees. $1,065.00 IANTCELFRE Cellular,Free-Standing Strong Motion Fee: IBSEISMICO $42.00 Wireless MasterTt-p n Bldg,Stds Commission Fee: IBCBSC $8.00 $1,217.00 IwMPL (� e SUBTOTALS: $50.001$2,282.001 TOTAL FEE: 1 $2,332.00 Revised: 07/01/2012