14060017 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10123 N WOLFE RD CONTRACTOR:TOTAL PERMIT NO: 14060017
ENVIRONMENTAL&POWER SYSTEMS
OWNER'S NAME: VALLCO SHOPPING MALL LLC 2500 BISSO LN APT 500 DATE ISSUED:02/09/2015
OWNER'S PHONE: 4087773081 CONCORD,CA 94520 PHONE NO:(925)681-2238
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
REPLACE(E)ANTENNA'S ON VALLCO WITHIN VALLCO
License Classc— 10 , Z 0 Lic.# __7(LA y FASHION PARK MONUMENT SIGN
Contracto;771k 'S Date t�1 I
I hereby affirm that I am licensed under the provisio s of C apter 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:$15000
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:31620103.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application d state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city arid county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building constr ction,and hereby Lre entatives of this city to enter
upon the above ntioned prop for rposes. (We)agree to save LED INSPECTION.
indemnify and k p harmless e City 0 against liabilities,judgment
costs,and expen s which y accrue a aity in consequence of thegranting of this unit. Ad 'tio ally,the nderstands and will complyby:with all non-poi source reg lag ons per no Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date Z 5 All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,l 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)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS D E
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials require ents unde hap er 6.95 of the
California Health&Safety Cod Sections 5505,25533 a d 2 34. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the C ertino unicipal Cod ha ter 9.12 and the
declarations: Health&Safety Code,Section 2 32(a)sh uld I store o h nd hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,sdScetio25505,255
ip ent r devic s h' h emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defirea it Quali agement District I
performance of the work for which this permit is issued. will maintain compliancrtino u icipal de,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Cod , nSection 3700 of the Labor Code,for the performance of the work for which thisOwner or authorized agate:Z
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
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,l must l 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
1 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.
CITY OF CUPERTINO
FEE ESTIMATOR- BUILDING DIVISION
ADDRESS: 10123 N WOLFE RD DATE: 06/04/2014 REVIEWED BY: MELISSA
APN: 316 20 103 BP#: IV0000 'VALUATION: 1$15,000
`,'PERMIT TYPE: Building Permit PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building PENTAMATION TELECOMFAC
USE: PERMIT TYPE:
WORK REPLACE E ANTENA'S ON VALLCO WITHIN VALLCO FASHION PARK MONUMENT SIGN
SCOPE
Ll Ll —I_
NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc . Thesefees are based on the prelimina information available and are only an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff Z%1!13) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 Select a Misc Bldg/Structure
Suppl. PC Fee: (j) Reg. 0 OT 0
.01 hrs $0.00 or Element of a Building
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Feer Reg. 0 OT 0.0 1 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
0
Work Without Permit? 0 Yes ) No $0.00 G
Advanced Planning Fee: $0.00 0 # Antenna- Telecom Facility 0
$1,112.00 IANTCELATl Cellular,Attached to Bldg
Strong Motion Fee: IBSEISMICO $3.15 Select an Administrative Item
Bld, Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $4.151$1,112.001 TOTAL FEE: $1,116.15
Revised: 04/01/2014