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13040106CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 5 RESULTS WAY CONTRACTOR:•fBO-44)-BE ICER vfD PERMIT NO: 13040106 OWNER'S NAME: ECI TWO RESULTS LLC DATE ISSUED: 04/23/2013 OWNER'S PHONE: ne V V reoS 11 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL Class Licc# O ��� INSTALLATION OF (3) LTE RRU'S ONTO (E) 3 INCH License V1 STEEL PIPE WITHIN AN (E) CELL SITE ENCLOSURE Contractor 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: 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: $7000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 35720041.5 Occupancy 'I cpe: Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION I certify that I 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 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 D S ROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, City in of the G� costs, and expenses which accrue against said consequence "di- Issued by Date: / granting of this permit. A onally, the applicant understands and will comply with all in - source egu tions per the Cupertino Municipal Code, Section A- 9.18atu. RE -ROOFS: SignDate*�l 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. 11OWNER- UILDER DECLARATION Signature of Applicant: Date: 1 hereby affirm that I am exempt from the Contractor's License Law for one of 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) 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. 1 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(x) should I store or handle hazardous 1 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 th ertino Municipal Code, Chapter 9.12 and 1 have and will maintain Worker's Compensation Insurance, as provided for by the Health &Safety Code, 25 5, 25533, and 25533 Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent ate Z 3 permit is issued. 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 CONSTCTION LENDING AGENCY RU Compensation laws of California. If, after making this certificate of exemption, I 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 ARCHITECT'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 INCULUMS Paul Foster 10 Pasteur Dr. Suite 100 Irvine, CA 92618 (949) 783-3550 April 2, 2013 Rei Contractor's License # 924523 Class B with additional Certification of C-10 Vinculums Service Inc. To Whom It May Concern: The following individuals are authorized to pull permits on behalf of Vinculums Services Inc. • Michelle Martinea • Anthony Matricia • Cindel Pena • Allan Casebier Sincerely, Paul Foster, President and RMO /rm Vinculwns Services, Inc. 10 F aste.w, Snits• 10U lo,m. I:A 92618 w 949.782.5400 GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 950143255 (408) 777-3228 • FAX (408) 777-3333 • building a5cuoertino.org MISC CUPERTFNO /_36/ Iokl F-1 PT i Tixpr-�jr; FjMF(74ANI('AT. ELECTRICAL FJMISCEELLANEOUS PROJECT ADDRESS IOn c „ ,^ r_ APN # 3 95T, Z00 ZZ • OW'NERNAME I Y 1 v jl I I PHOq� ,-�JY3..:?Z7) E-MAIL l VS�j STREET ADDRES 6 CITY TA . Z C OV4 FAX CONTACT NAME �^ +? < PHONE E-MAIL ✓r.-� •ALO j,n., STREETADDRESS CITY, STATE, ZIP FAX ❑ OWNER ❑ OWNER-BUIIAER ❑ OW'NER AGENT CONTRACTOR ❑ CONTRACTOR AGENT ❑ .ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENATT CONTRACTOR NAME v •, 1 ' ,y.�(/I LICEN TSL E}� I � 11 CEN SE.� = ` O C� BUS. LIC r• COMPANY NAME �% I n CLQ U'" S Y i � E WWW STREET ADDRES� I Q (� nO n [ j y� jL 1� CITY, STA ,ZIP H�1 C(/�� P� ARCHITECT/EWr:rrrF=a *'a"=lam/' 1 �JW`1"awd 00 LICENSE NUMBER C ' 11 O[ v` J BUS. LIC ## COMPANY NAME ' y�( fee, e 0 It E-MAIL FAX 2 O� st. STREET ADDRESS (IIC for CITY, STA IPr ( (J USE OF ❑ SFD DUPLEX ❑ MULTI -FAMILY BUILDING: MI�RCI AL TPROJECT IN WILDLAN) ❑ YES URBAN INTERFACE AREA NO PROJECT IN ❑ YES FLOOD ZONE NO IS THE BLDG AN ❑ YES EICHLER HOME? i.0 I 1 � C ,n ` J I DESCRIPTION OFel �[W�O ,, 01 � (� (t- TOTAL VALUATION. V Il / 1 RECEIVED BY: By my signature below, I certify to each of the followin I am the property owner or authorized agent to act on the property owtIer's behalf. I have read this application and the information I have vie is orre I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to b n o cti I authorize representatives of Cupertino to enter the above -identified propel& for inspection pu@oses. Signature of Applicant/Agent: Date: �i l -1 SUPPLE NTAL TFORMATION REQUIRED OFFICE USE ONLY OVER-THE-COUNTER ❑ EXPRESS v U ❑ STANDARD Z < ❑ LARGE ❑ MAJOR IgP.WiscApp_2011.doc revised 06121111 CITY OF CUPERTINO �� vivr r Q: rlIX4 A rnR _ RITII .DING DIVISION lia 1' iJ •'L iJAJ 1 1 ADDRESS: DATE: ` REVIEWED BY: h1i>c;h. Permit Fc. APN: BP#: Qlb 1 "VALUATION: 1$7,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement PRIMARY USE: Commercial Building Plumb. Insp. Fee: PENTAMATION 1 GENCOM PERMIT TYPE: A WORK Installation of 3 LTE RRU's onto existing 3 inch steel pipe within an existing cell site enclosure. SCOPE NOTE: This estimate does not include fees due to other Departments (/.e. manning, ruouc rrvrna, 11 sic, . "111 y �•�•• • •r [' ormat t'on available and are onlyan estimate. Contact the De t or addn'l in o. District, etG). These ees are based on the re tmtna FEE ITEMS (Fee Resolution 11-053 Ef ' 7•f 1,"121 ll c:ii. /'(art t herr. 'hunb. Plan Check Elec. Plan Check h1i>c;h. Permit Fc. Plumb. Permit Fee: Elec. Permit Fce: Other Alech. Insp. :Nher Plumb Insp. Other Elco Insp. Mech. Insp. Fee- Plumb. Insp. Fee: i,'� < h��r� Fee: $0.00 PME Plan Check: $0.00 NOTE: This estimate does not include fees due to other Departments (/.e. manning, ruouc rrvrna, 11 sic, . "111 y �•�•• • •r [' ormat t'on available and are onlyan estimate. Contact the De t or addn'l in o. District, etG). These ees are based on the re tmtna FEE ITEMS (Fee Resolution 11-053 Ef ' 7•f 1,"121 to FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? Q Yes Q No $0.00 1 1 hours Plan Check, Hourly $133.00 ISTPLNCK Suppl. PC Fee: 0 Reg. Q OT 0.0 1 hrs $0.00 PME Plan Check: $0.00 Permit Fee: Hourly Only? ()Yes ONO $0.00 Suppl. Insp. Fee:Q Reg. Q OT Q,0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Construction Tax: Administrative Fee: o 0 Work Without Permit? © Yes Q No $0.00 Advanced Planning Fee: $0.00 F 1 ] hours Inspections $133.00 ISTINSP Inspection, Hourly G 0 Trawl et Doctnnentation Fees: Strong Motion Fee: 1BSEISMICO $1.47 Select an Administrative Item Rld(_, Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $2.47 $266.00 TOTAL FEE: $268.47 Revised: 04/01/2013 '56c -/ /1 / L'/