10090082CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6191 BOLLINGER RD CONTRACTOR: NSA WIRELESS INC PERMIT NO: 10090082
C 'BR'S NAME: WEST VALLEY PRESBYTERIAN CHURCH
OWNER'S PHONE: 4082530735
P LICENSED CONTRACTOR'S DECLARATION
License Class ff 6jEfU Lic.# AI?S,J&V g
Contractor W_�2 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 affirm under penalty of perjury one of the following two declarations:
t. 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.
2. I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the perfonnance 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 this permit. Additionally, the applicant understands and will comply with
all non -point source regulations per the Cupertino Municipal Code, Section 9.18.
Sienatur �lu� J��_6(61_74X -C6C.- Date %/
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. I, 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:
1. 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.
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
permit is issued.
3. 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 infonnation 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
the above mentioned property for inspection purposes. (We) agree to save
mify and keep harmless the City of Cupertino against liabilities, judgments,
cots, 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.
Signature
Date
2000 CROW CANYON PL STE 400
SAN RAMON, CA 94583
DATE ISSUED: 11/04/2010
PHONE NO: (925) 244-1890
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
CHURCH STEEPLE - CLEARWIRE TO BUILD CELL SITE WTIH
(3) PANEL ANTENNAS & (3) THREE MICROWAVE ANTENNAS
IN FAUX STEEPLE W/EQUIPMENT ON GROUND PAD
Sq. Ft Floor Area: I Valuation: $25000
APN Number: 37541007.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by Date:
/,-1 y-4,.,
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:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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. I 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
Health & Safety Code, Sections 25505, 25533, and 25534.
Owy"er or authorize ent:
tic:"� Date:
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Profession
I CITY OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 6191 BOLLINGER RDI CONTRACTOR• 'PRTI Tn nc I PERMIT NO: 10090082 I
DF.TF� RMT_
I OWNER'S NAME: WEST VALLEY PRESBYTERIAN CHURCH 1 tLyr► n ni n w /',,,.,,.,� ��.,. _ _ L J DATE ISSUED: 11/04/2010 1
I OWNER'S PHONE: 4082530735 1 , I PHONE NO:
OY LICENSED CONTRACTOR'S DECLARATION
License Class_ Lic. #
Contractormto (' i Can A 41414 n,a1 49PS CL 0 /U
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:
t. 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.
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
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 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 permi Ad!9fn!T
ds and will comply with
all non -point sour egulatCode, Section 9.18.
Signatur a i U
❑ O ER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. 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)
2. 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:
t. 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.
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
permit is issued.
s. l 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, 1
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.
Signature
Date
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
CHURCH STEEPLE - CLEARWIRE TO BUILD CELL SITE WTIH
(3) PANEL ANTENNAS & (3) THREE MICROWAVE ANTENNAS
IN FAUX STEEPLE W/EQUIPMENT ON GROUND PAD
Sq. Ft Floor Area: I Valuation: $25000
APN Number: 37541007,00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
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 COVERINGS TO BE CLASS "A" OR BETTER
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. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) 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
Health & $afety Code, Sections 25505, 25533, and 25534.
Own authori nt:
Date: a016
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6191 BOLLINGER RD
CONTRACTOR: NSA WIRELESS INC
PERMIT NO: 10090082
OWNER'S- A,ME: WEST VALLEY PRESBYTERIAN CHURCH
2000 CROW CANYON PL STE 400
DATE ISSUED: 11/04/2010
OWNER'S PHONEI-,4082530735
SAN RAMON, CA 94583
PHONE NO: (925) 244-1890
�I LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDEN AL ❑ COMMERCIAL ❑
CHURCH STEEPLE - CLEAR TO BUILD CELL SITE WTIH
License Class %� Lic. 9
(3) PANEL ANTENNAS & (3) E MICROWAVE ANTENNAS
IN FAUX STEEPLE W/EQU ENT ON GROUND PAD
Contractor � r2 Date /
1 hereby affirm that 1 am licensed under the pr 'sions of Chapter 9
(commencing with Section 7000) of Division 3 of t Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the follows two declarations:
Sq. F loor Area:
Valuation: $25000
1. 1 have and will maintain a certificate of consent to self -insure Worker's
Compensation, as provided for by Section 3700 of the Labor Co for the
APN Number: 37541007.00
Occupancy Type:
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance, as provide or by
Section 3700 of the Labor Code, for the performance of the work for whit s
permit is issued.
PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above info ation is
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
correct. I agree to comply with all city and county ordinances and s to laws relating
180 DAYS FROM LAST CALLED INSPECTION.
to building construction, and hereby authorize representatives of is city to enter
upon the above mentioned property for inspection purposes. e) agree to save
y
indemnify and keep harmless the City of Cupertino against h ilities, judgments,
Issue y Date: l_
costs, and expenses which may accrue against said City in nsequence of the
granting of this permit. Additionally, the applicant unde [ands and will comply with
all non -point source regulations per the Cupertino Mu cipal Code, Section 9.18.
RE -ROOFS:
SignaturthfL2i Date l/ lalm
All roofs shall be i petted prior to any roofing material being installed. If a roof is
installed without firs btaining an inspection, I agree to remove all new materials for
inspection.
❑OWNER -BUILDER DECZARATION
Signature of Applicant: Date:
hereby affirm that 1 am exempt fro he Contractor's License Law for one of
the following two reasons:
ALL ROOF COVE NGS TO BE CLASS "A" OR BETTER
1. I, as owner of the property, or my mployees with wages as their sole
compensation, will do the work d the structure is not intended or offered for
sale (Sec.7044, Business & P fessions Code)
HAZARDOUS M ERIALS DISCLOSURE
2. 1, as owner of the property, m exclusively contracting with licensed contractors to
I have read the hazardous materials requi ments under Chapter 6.95 of the
construct the project (Sec 044, Business & Professions Code).
California Health & Safety Code, Sections 2 05, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Cod Chapter 9.12 and the Health &
I hereby affirm under nalty of perjury one of the following three declarations:
Safety Code, Section 25532(a) should 1 store or h die hazardous material.
t. I have and will mai in a Certificate of Consent to self -insure for Worker's
Additionally, should I use equipment or devices wh emit hazardous air
Compensation, as rovided for by Section 3700 of the Labor Code, for the
contaminants as defined by the Bay Area Air Quality anagement District 1 will
maintain compliance with the Cupertino Municipal Co Chapter 9.12 and the
performance of a work for which this permit is issued.
Health & Safety Code, Sections 25505, 25533, and 25534.
2. I have and wi maintain Worker's Compensation Insurance, as provided for by
Section 370 of the Labor Code, for the performance of the work for which this
permit is i ued.
Owner or authorized agent:
.A&`_Coty;4 Okx Date: !( (!
3. I certify at in the performance of the work for which this permit is issued, I shall
not em oy any person in any manner so as to become subject to the Worker's
CONSTRUCTION LENDING AGENCY \_
Com nsation laws of California. If, after making this certificate of exemption, I
I hereby affirm that there is a construction lending agency for the performance work's
become subject to the Worker's Compensation provisions of the Labor Code, I
forthwith this be deemed
for which this permit is issued (Sec. 3097, Civ C.)
mut comply with such provisions or permit shall
Lender's Name
revoked.
Lender's Address \ .
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
ARCHITECT'S DECLARATION
correct. I agree to comply with all city and county ordinances and state laws relating
I understand my plans shall be used as public records.
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Licensed Professional
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.
Signature Date
CITY OF CUPERTINO
Fm,-� FEE ESTIMATOR - BUILDING DIVISION
NOTE: These fees are based on the Dreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10)
ADDRESS:
Phunb, Plun ChcckT-T
DATE:
REVIEWED BY:
Pltrmh. Perma Fee.
APN:
BP#:
"VALUATION:
Iso
*PERMIT TYPE: Building Permit
Plumb. h/sp. Fee:
PLAN CHECK TYPE: Tenant Improvement
PRIMARY Commercial Building
USE:
$0.00
TOTAL
FLOOR .44[-,,1:
PENTAMATION TELECOMFAC
PERMIT TYPE:
WORK
SCOPE
Permit Fee:
$0.00
NOTE: These fees are based on the Dreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10)
Mc'ch. Alan Chock
Phunb, Plun ChcckT-T
]7uc:. Plan Chcck
-1ch. Permit Fee.
Pltrmh. Perma Fee.
Dec. Permit Fee:
Ih'c l7. Insp.
Lh
0(her Plumb Imp.Li
U1her 1-1c(. lnsp.
. Imp. F<<e:
Plumb. h/sp. Fee:
Elc(. Insp.
NOTE: These fees are based on the Dreliminary information available and are only an estimate. Contact the Dent for addn'1 info.
FEE ITEMS (Fee Resolution 09-051 Eff. 7/1/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: E) Reg. 0 OT
0.0
hrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:(' Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Cons1»rc tion Tax
Acoustical Fee: 0 Yes (E) No
$0.00
0
0
Work Without Permit? 0 Yes 0 No
$0.00
Planning Fee:
$0.00
6 #
$6,078.00
Antenna - Telecom Facility
IANTCELATT I Cellular, Attached to Bldg
0
0
Travel Docu(nenlution Fees:
Strong Motion Fee:
$0.00
$1,158.00
Wireless Master Plan
1WMPLNFE
Bldg Stds Commission Fee:
$0.00
SUBTOTALS:
$0.00
$7,236.001TOTAL
FEE:
1 $7,236.00
Revised: 9/01/2010