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12040078 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 22475 RANCHO DEEP CLIFF DR CONTRACTOR:BOTHWELL PERMIT NO: 12040078 CONSTRUCTION CORP OWNER'S NAIVE: HOFFMAN M SAUL AND YVONNE T TRUSTEE 1590 INDUSTRIAL AVE DATE ISSUED:06/28/2012 OWNER'S PHONE: 4084463369 SAN JOSE,CA 95112 PHONE NO:(408)298-8049 ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMMERCIAL License Class Lie.Lie.# �e BEHIND HOUSE-AT&T INSTALLATION FOR WIRLESS FACILITY ON AN EXISTING VERIZON OWNED Contractor� CVIWP�\.1 T1A�i UC'�l®1?ate L'2�l?.� MONOPINE. I hereby affirm that I am licensed under the provisions of Chapter 9 AT&T EQUIPMENT CABINETS ALSO PROPOSED (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 deelarations: 1 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:$50000 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for die performance of the work for which this APN Number:35602032.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION 1 certify that 1 have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.l 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 DA S FROM 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 granting of this permit. Additio , c applicant understands and will comply Issued by: G Date: with all non-point source regutati s per t e Cupertino Municipal Code,Seetion 9.1 S. RE-ROOFS: St lure DateAll roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,1 agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION Signature of Applicant: Date: I 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 1,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(See.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). 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 1 store or handle hazardous 1 have and will maintain a Certifieate 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 compli•nce with the Cuper`no icipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Co Section 5505,�15,53;,a d 25534. Section 3700 of the Labor Code,for the performance of the work for which this 6 2�-CZ permit is issued. Owner or authorize�•'.I�er atc: 1 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 certifieate 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 1 certify that I have read this application and state that the above information is correct.1 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 CITY OF CUPERTINO FEE ESTIMATOR-BUILDING DIVISION ADDRESS: 22475 Rancho Deep Cliff DATE: 0410412012 REVIEWED BY: APN: BP#: 149q007 S *VALUATION: 1$50,000 *PERMIT TYPE: Building Permit PLAN CHECK TYPE: PRIMARY Commercial Building PENTAMATION_14�&n USE: PERMIT TYPE: WORK AT&T installation for wireless facilityon an existingVerizon owned monopine. AT&T equipment " SCOPE cabinets also proposed. OCCUPANCY TYPE: TYPE OF FLR AREA PC FEES PC FEE ID BP FEES BP FEE ID CONSTR s.f. nt Improv ents) I-B,III-B, $0.00 .0 TOTALS: 0 $0.00 $0.00 MECH,HOURLY Q Yes O No PLUMB,HOURLY Q Yes Q No ELEC,HOURLY Q Yes Q No 4f,"ch. pl'oo,('n ;:'r Pl�rrah. 1'I:xr;Chet -k I-F tier. Plnr;C'nu it Permit Pe Piur..l:,.1'a nri?Pec: i i<<., !:1,'in a1.,.ia.asl:• 1?1;a','Pl+u:i';;'rasp, !},'.•' Lj lf. ...bKs1r l ce' Phwr(r. lwp' NOTE: This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc . These.fees are based on the prelinifna information available and are only an estimate. Contact the De t oraddn'l info. FEE ITEMS 0"ce Resolution 11-053 Efr 7,'1/11) FEE QTY/FEE MISC ITEMS Plan Check Fee: Hourly Only? ®Yes 0 No $0.00 I I hours Plan Check,Hourly Suppl. PC Fee: (F) Reg. o OT 0.0 hrs $0.00 wool I PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. Q OT Q,Q hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: -T-T $0.00 ( onstr114:11ura Tax: ic.lnrin.istrcl4 e Fee: 1� # Antenna -Telecom Facility � Work Without Permit? © Yes 0 No $0.00 $1,044.00 1,4NTCEL,4TT I Cellular,Attached to Bldg O Advanced Planning Fee: $0.00 # Antenna-Telecom Facility O Tl-avci Docrrrncr�r�lclvu 1'eus $0.00 Cellular,Attached to Bldg o Strone Motion Fee: IBSEISMICO $10.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $2.00 SUBTOTALS: $12.50 r$1,044.001 TOTAL FEE: r $1,056.50 Revised: 111912012