B-2017-1980` CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1980
103.35 N TANTAU AVE CUPERTINO,CA 95014(316 06 064) S C BUILDERS INC
SUNNYVALE,CA
94085
OWNER'S NAME: CAMPUS HOLDINGS INC DATE ISSUED:03/20/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Ia Lic.#767196
Contractor S C BUILDERS INC Date 08/31/2019 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
AC2-INSTALL WIRELESS ANTENNA FACILITIES ON ROOF OF
I hereby affirm under penalty of perjury one of the following two declarations: BUILDING(TANTAU 9)FOR AT&T(8 ANTENNAS),SPRINT(8
1. I have and will maintain a certificate of consent to self-insure for Worker's ANTENNAS),T-MOBILE(6 ANTENNAS),VERIZON(12 ANTENNAS);
Compensation,as provided for by Section 3700 of the Labor Code,for the (N)45kVA POWER DISTRIBUTION SYSTEM FOR CELL CARRIER
performance of the work for which this permit is issued. EQUIPMENT IN ROOM 02D2;(N) 112.5kVA POWER DISTRIBUTION
I have and will maintain Worker's Compensation Insurance,as provided for by SYSTEM FOR CELL CARRIER ANTENNA EQUIPMENT IN
Section 3700 of the Labor Code,for the performance of the work for which this ELECTRICAL ROOM 53M2.
permit is issued. DEFERRED SUB#1: ROOF SCREEN MODIFICATIONS AND
APPLICANT CERTIFICATION SPECIFICATIONS.ISSUED 9.13.18
1 certify that I have read this application and state that the above Sq.Ft Floor Area: Valuation:$250000.00
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 APN Number: Occupancy Type:
inspection purposes. (We)agree to save indemnify and keep harmless the 316 06 064 A(Tenant Improvements)
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 applic nt understands and will comply with all non-point
source regulations the Cupertino Municipal Code,Section 9.18. PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Signature Date 9.13.18 180 DAYS FROM LAST CALLED INSPECTION.
OOV
OWNE E LARATI N Issued by:SEAN HATCH
I hereby affirm that I ant exempt from the Contractor's License Law for one of the Date:03/20/2018
following two reasons:
1. I,as owner of the property,or my employees with wages as their sole RE-ROOFS:
compensation,will do the work,and the structure is not intended or offered for All roofs shall be inspected prior to any roofing material being installed.If a roof is
sale(Sec.7044,Business&Professions Code) installed without first obtaining an inspection,I agree to remove all new materials for
2. I,as owner of the property,am exclusively contracting with licensed inspection.
contractors to construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three declarations: Signature of Applicant:
t. I have and will maintain a Certificate of Consent to self-insure for Worker's Date:9.13.18
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
permit is issued. I have read the hazardous materials requirements under Chapter 6.95'of the
3. I certify that in the performance of the work for which this permit is issued,I California Health&Safety Code,Sections 25505,25533,and 25534. I will
shall not employ any person in any manner so as to become subject to the maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Worker's Compensation laws of California. If,after making this certificate of Health&Safety Code,Section 25532(a)should I store or handle hazardous
exemption,I become subject to the Worker's Compensation provisions of the material. Additionally,should I use equipment or devices which emit hazardous
Labor Code,I must forthwith comply with such provisions or this permit shall air contaminants as defined by the Bay Area Air Quality Management District I
be deemed revoked. will maintain compliance with the Cupertino unicipal Code,Chapter 9.12 and
the Health&Safety Cade,Se 25505,25533,and 5534.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is Owner or authorized agent:
correct.I agree to comply with all city and county ordinances and state laws Date:9.13.18
relating to building construction,and hereby authorize representatives of this city Y
to enter upon the above mentioned property for inspection purposes. (We)agree I hereby affirm that there is a onstruction lending agency for the performance
to save indemnify and keep harmless the City of Cupertino against liabilities, of work's for which this permit is issued(Sec.3097,Civ C.)
judgments,costs,and expenses which may accrue against said City in Lender's Name
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal Lender's Address
Code,Section 9.18.
ARCHITECT'S DECLARATION
Signature Date 9.13.18 1 understand my plans shall be used as public records.
Licensed