11090204CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 10420 BUBB RD
OWNER'S NAME: THE HOME OF CHRIST CHURCH
OWNER'S PHONE: 4085222700
E] LICENSED CONTRACTOR'S DECLARATION
License Cla�s._ Lic. # 0
r__�
Contractor (;�� OuJILZ�A— Date
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 afflrm 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.
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
permit is issued,
APPLICANT CERTIFICATION
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
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 thi . t - Additionally, the applicant understands and will comply
s.p�rml
with all non-po so rce regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date 'J,- '2—cl
El OWNER-BUILDE R DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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 (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
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.
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
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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
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. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18,
CONTRACTOR: CAPITAL TOWER AND PERMIT NO: 11090204
COMMUNICATIONS
13330 AMBERLY RD DATE ISSUE D: 09/29/2011
WAVERLY, NE 68462 PHONE NO: (404) 786-3333
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB f—
MECH r RESIDENTIAL r COMMERCIAL J_
JOB DESCRIPTION: T -MOBILE WEST CELL TOWER - REMOVE & REPLACE AN
EXISTING BTS CABINET WITH A NEW BTS CABINET FOR
T -MOBILE WEST CORPORATION
Sq. Ft Floor Area: I Valuation: $5000
APN Number: 35720038.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DYYS FROMEAST CALLED INSPECTION.
Issued by: tm—�,5 Date:
e
RE -ROOFS:
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,
Signature of Applicant: Date:
ALL ROOF COVE RINGS TO BE CLASS "A" OR BETTE, R
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain cOmpliance with the Cupertino Municipal Code, Chapter 9.12 and the
114ealthe�kCode, Sections 25505,25533, and 25534.
0 ne or a li ized agent:
Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of NNork's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date I Licensed Professional.
N
�5f C)/� <56 A
CONSTRUCTION PERMIT APPLICATION KI
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISIOV/,(") / B
10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 o 2-6
(408) 777-3228 - FAX (408) 777-3333 - bUildin Cup, Fmo.o g
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71 1 -1-1 M M L�11IQI111T/T1rT7T7T?T?wT1 rV?TC11NIAT PPRXfflTV
PROJECT ADDRESS
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OWNERNAME 11� QXA--cy U
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STREET A?NC
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1-1 OWNER OWNER -BUILDER OWNER AGENT CONTRACTOR 11 CONTRACTOR AGENT ARCHITECT ENGINEER 1:1 DEVELOPER 0-9N
-I,-
CONTRACTORNAME CAP
LICENSE NUMBER
C)
YPE
'AT ID
BUS. LIC # -7
COMPANYNAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
Lk)"EOPY ILL
PHONE 6
ARCHITECT/ENGTNEER NAME _710ENSENUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK er-_ At,) 1) PEN Ace- Ar,)
k T-tA- C ---
(k) CC) e -Po P -AT -1 (3
EXISTING USE
I
PROPOSED USE
I
CONSTR. TYPE
STORIES
OFFICE USE
NLY
OCC.
TYPE
DESCRIPTION
SO -FT.
VALUATION
EXISTG
NEW FLOOR
DEMO
TOTAL
AREA
AREA
AREA
NET AREA
BATHROOM
KITCHEN
OTHER
REMODELAREA
REMODELAREA
REMODELAREA
PORCH AREA
DECK ARE
I
TOTAL DECK/PORCH AREA
I
GARAGE AREA: DETACH
I ATTACH
4 DWELLING UNITS:
IS A SECOND UNIT YES
SECONDSTORY YES
BEING ADDED? NO
ADDITION? NO
PRE -APPLICATION YES
IF YES, PROVIDE COPY OF
PLANNER'S N
RECEIVED BY:
TOTAL VALUATION:
PLANNING APPL # NO
PLANNING APPROVAL LETTER
By my signature below, I certify t h f the follo . n thte property owner or authorized agentto act on the property owner's behalf. I have read this
IT C � V�d the Description o
application and the inforrnatio� TO - ed is Tree I h e f Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relat, gt I uil ng con ructi I th prcsentatives of Cupertino to enter the above-iden tied prpperty for inspection purposes.
Signature of Applicant/Agen Dal
SUPPLEMENTAL INFORMATION REQUIRED
V�AN CHECK TYPE
ROUTING SLIP
a107 --
VrR-TIIE-COUNTER
El iFxPREss
El BUILDING PLAN REVIEW
El PLANNING PLAN REVIEW
*
New SFD or Multifamily dwellings: Apply for demolition permit for
existing building(s). Demolition permit is required prior to issuance of building
permit for new building.
Commercial Bldgs: Provide d completed Hazardous Materials Disclosure
El STANDARD
F-1 PUBLIC WORKS
form if any Hazardous Materials are being used as part of this project.
El LARGE
El rIRE DEPT
— Copy of Planning Approval Letter or Meeting with Planning prior to
submittal of Building Permit application.
MAJOR
171 SANITARY SEWER DISTRICT
ENVIRONMENTAL HEALTH
BldgApp_201 1. doc revised 03116111
on
11514-
CITY OF CUPERTINO
F9i R-72 FEE ESTIMATOR — BUILDING DIVISION
60, ADDRESS: 10420 bubb road
FEE ID
DATE: 09/29/2011
REVIEWED BY: larrys
APN:
I BP#:
NALUATION: 1$5,000
'�TERMIT TYPE: Electrical Permit
--[PLAN
CHECK TYPE: Alteration / Addition / Repair
PRIMARY Commercial Building
USE:
#
PENTAMATION 1 CEAP7
PERMIT TYPE:
WORK
SCOPE
F
APPLIANCE / EQUIP TYPE
FEE ID
QTY/FEE
QTY
UNITS
BP FEES
Elce, Permit Fee: IEPERMT
Apparatus
1BREMMISC
Other Elec. Insp, 6-61 hrs $44.00
h. 1wp, Free.,
#
$130
F
PME Unit Fee:
$130.00
PME Permit Fee:
$44.00
�"-o'q'vowcfiun Tax
Administrative Fee: IADAffN
$41.00
Work Without Permit? 0 Yes 0 No
$0.00
TOTALS:
'A
Travel Documentation Fee: JTR.4VD0C
1 $130.001
Strowl, Motion Fee: IBSEISMCO
NOTE.- This estintate does not includefees due to other Depts (I.e. Public Works, Sanitary Sesver District, School District, etc.).
Thpvp foo.v arp havpd nn thp nroliminary inforinalion availahle and are on1v an estimate. Contact the DeDt for addn'l info.
FEE ITEMS (Fee Resohition 11-053 ET 7/M
�i. Cho
QTY/FEE
Elec. Plan Check 1 0.0 1 hrs $0.00
Elce, Permit Fee: IEPERMT
L
� -Iu"�ab
Other Elec. Insp, 6-61 hrs $44.00
h. 1wp, Free.,
PME Plan Check:
$0.00
NOTE.- This estintate does not includefees due to other Depts (I.e. Public Works, Sanitary Sesver District, School District, etc.).
Thpvp foo.v arp havpd nn thp nroliminary inforinalion availahle and are on1v an estimate. Contact the DeDt for addn'l info.
FEE ITEMS (Fee Resohition 11-053 ET 7/M
FEE
QTY/FEE
MISC ITEMS
PME Plan Check:
$0.00
F
PME Unit Fee:
$130.00
PME Permit Fee:
$44.00
�"-o'q'vowcfiun Tax
Administrative Fee: IADAffN
$41.00
Work Without Permit? 0 Yes 0 No
$0.00
'A
Travel Documentation Fee: JTR.4VD0C
$44.00
Strowl, Motion Fee: IBSEISMCO
$1.05
Select an Administrative Item
-1
Bld,g Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$261.051
$0.001 TOTAL FEE:
$261.
Revised: 09/02/2011