06030165 CITY OF CUPERTINO T171W
BUILDING DIVISION PERMIT ..�ONTR°AGTnRINFORMATIO.N ;
h2,.'E rasx,
BUILDING ADDRESS: MC SHANE THOMAS J AND BIR TYV790 06030165
21760 STEVENS CREEK BLVD
OWNER'S NAME: PERMIT ISSUE DATE
MC SHANE THOMAS J AND BIRU A S 06/12/2006
ONE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
pQ LICENSED CONTRACTOR'S DECLARATION
Job Description
i u�j 1 MrebY affirm Nal I am Ikxnud umkr pmvitlans of CMpmr 9(commencing
;Ion weed Section 7ggy)af Di Ion Jof NC Budnev d fcssiu dmyliccnseu
�„ mranmmeanaercmt INSTALLATION OF ANTENNAS & ASSOCIATED EQUIPMENT
'4z L1LC0S y'a F T-MOBILES NETWORK. INSTALL 3 ANTENNAS INSIDE
t„o One Comncmr
1 ARCHRECTSDEC A ATION OF STELTH CHIMNEY & ASSOCIATED E
i < 1understand myplans shall Mused upublic mcords EQUIPMENT CABINE
to
{�
G Licensed Professional
OWNER-BUILDER DECLARATION
5 1 Withy affirm that I am exempt from the Contractors License Law for tM
O o following moon.(Sccumn 7031.5,Business and Pmferslrns Coda:My city at county
m which mquims a permit m crosoum.allot improve,demolish,as repair any svuctute
prior tit is iuurnum.and mquira ton applicand for such permit to file a signed summer
3�t] that he is licensed pursunnito the provisions of the Convactma Liems,Law lChapmr 9 Sq.Ft. Floor Area Valuation
d (commencing with Section 70)0)o(Divulon 3 of Ne Business and Pmfessions Cods)or .$75000
— Nu M is exempt therefrom and the basis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type
not mart Nan five hundred dollar(3500).
I,u owmr of the pmpwy,or my employca with wages o Coir mle compensadon,
will do the work.and Ne svucture u notintemed or offered formlc(Sec.7066.Business Required Inspections
and Pr dfesuoo Code The Conuscmra Lice.Law doss Out apply to an..of q p
property who builds orimPmves thermn,and whodeeseuch work hitmelfor through his
awn employers,provided Nat such improvements art note rumded aroffered for sale.If.
however.the Wilding or improvement u sold within one year of mmplefion,the owner.
builder will nave the burden of proving that M did not Wild or improve for purpose of
sale.).
❑1,o tweet of ct property,.m exness and convaming with licensed mnwcmrs m �
mane a it project(Sec.7066,owner
and property
whoans Code:)The Canmcmr's and roe law dos not apply je an owns of proper(who Mildsra norma Centro.and
whocontractsLacs for such projects with a convanorts)licensed punwnt m Ne Canuactors
Lice
Owner Law. Ll—. /
❑I an exempt under Sec .B&P C for Nu mason
Owner Dam V
WORKER'S COMPENSATION DECLARATION
1 Mmby affirsn under penalty of perjury ane of the following declarations:
h..e aM wBl msinW.a Certificate of Cement m self-insure fm worYcrs Camper- (�
n,u pmtlded far by Section 3700 of the labor Code,for the performanm of the
ark for which this permit is issued.
1 have and will maintain Workers Compensation nuutvhm,u required by Section
700 of the labor Code,for Ne performance r(the work for which dust mashis issued. '
My Wor� .anvartier and Policy num
Ganer. Policy G
n
fFlC FMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
(This scmlon dead not Mcomple cd if tM Permit is Immo hundred dollars($100)
or las_)
I cenifr Not in the performance of the work for which this Permit is issued.1 shall not
employ anyperson in any manrerae,u m become subject to the Worker'Compwatan
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If,afar making this Ger i furcad of Exemption,you should
biome mbjct as tM Workers Compenssuon Provisions of Ne labor Code,you mus
O foMwlN comply wish such provisions or Nis permit shall ho deemed evoked.
z" CONSTRUCTION LENDING AGENCY
F
I hereby affirm tut there is a constmctlnn lending agency err far the Performance of
lYi > theLe work for which this permit u issued(Sec.309'1,civ.CI
Le
G Q ddera Name
= Z Lenders Md.
U O 1 certify that 1 have mad this application and state Nu Cmc shove information is
IL corm".I agree to comply wit all city and county ordinances and sant laws elating to
C) building communion,and hereby authorim representative,of this city to enter upon the
rU shove-memomcd property for irspecuon purposes.
(We)agree to save,indemni ry,and kXP hamlcas the City Of Cupaninu Eagainst'fA liabiliva,judgmcns.casts and expcoa which may in any way accrue against said City
t.)Z in cohvequcrmc of the granting O(this permit /
^ APPLICANT UNDERSTANDS AND W LL CO WITH ALL NON-POINT Issued by: Date 5,-/,z a G
SOURCE R U O
Signa Of Applicant/ o r Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will she applicant Or future building ocetpantsom or handle Mastodons mamnai
in defined by to Cupenina Municipal Code.Chapter 9.12.and ftHealth and Safety
Cock,Section 155324)?
❑Yu $No All roofs shall be inspected prior to any roofing material being installed.
Will the.`pliant or future building ocupsm tare equipment or deviots which If a roof is installed without first obtaining an inspection,I agree to remove
7,,azammo air contaminants u defined by Ne Bay Area Air Quality Management all new materials for inspection.
a]Yes No
I hate mad Ne huafdous mamrialemumments underChapterd.95 ofNe Califonlthik SafetyCode.Sections 25505,25533 am 25536.lunderstand thsifCe Wilding
d curcmly have a meant Nat it u my responsihilby te notify to acupmt of the
men w ' hmuv ct tooia, Or.Ccrdramar 2 d� Signature of Applicant Date
or,aman> g DOW All roof coverings to be Class "B"or better