B-2018-1076 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1076
6191 BOLLINGER RD CUPERTINO,CA 95014-4630(375 41 007) VELEX INC
FRISCO,TX 75034
OWNER'S NAME: DATE ISSUED::01/25/2019
OWNER'S PHONE: PHONE NO:(972)581-9888
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C10 Lic.#994697
Contractor VELEX INC Date 07/31/2020 X BLDG _ELECT _PLUMB
_MECH—RESIDENTIAL X COMMERCIAL
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. JOB DESCRIPTION:
WEST VALLEY PRESBYTERIAN-CELL SITE MODIFICATION-
I hereby affirm under penalty of perjury one of the following two declarations: REPLACE(3)ANTENNAS WITH(6)ANTENNAS;INSTALL(9)RRUS;
1. I have and will maintain a certificate of consent to self-insure for Worker's REPLACE(1)RADIO CABINET AT GRADE;INSTALL(l)100A
Compensation,as provided for by Section 3700 of the Labor Code,for the POWER POINT OF CONNECTION CABINET;INSTALL WOOD GATE
performance of the work for which this permit is issued. ON EXISTING WOOD FENCE ENCLOSURE.
z. I have and will maintain Worker's Compensation Insurance,as provided for by
permit is issued. Sq.Ft Floor Area: Valuation:$20000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 41 007 A(Tenant Improvements)
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT. ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature, ~` Date 1-25-2019 Issued by:Kim Dunbar
Date:01/25/2019
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:1-25-2019
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
L 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. HAZARDOUS MATERIALS DISCLOSURE
a, I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued.
a. I certify that in the performance of the work for which this permit is issued,l Health&'Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent- _.�
APPLICANT CERTIFICATION Date: 1-25-2019
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction lending agency for the performance
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 of work's for which this permit is issued(Sec.3097,Civ C)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands
ARCHITECT'S DECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature Date 1-25-2019 Professional