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B-2016-1166 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1166 10121 MILLER AVE CUPERTfNO,CA 95014-346(369 07 001) PROCESS CELLULAR INC SANTA ANA,CA 92704 OWNER'S NAME: D&D REAL ESTATE LP DATE ISSUED:05/18/2016 OWNER'S PHONE:714-617-9921 PHONE No:(714)617-9921 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B C-10 C-20 Lic.#951819 Contractor PROCESS CELLULAR INC Date 08/31/2016 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: T-MOBILE-ADD TO(E)FREE STANDING CELL TOWER 3 I hereby affirm under penalty of perjury one of the following two declarations: ANTENNAS&3 RRU'S.ADD SUPPORTS/CROSS PLATES 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. 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 69 Number: Occupancy Type: 3 and state laws relating to building construction,and hereby authorize 369 07 001 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 CALLEMINSPECTION. Signature Date 5-18-2016 Issued by:Alex Vallelunea ' Date:05/18/2016 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:5-18-2016 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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. HAZARDOUS MATERIALS DISCLOSURE 2. 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. Health&Safety Code,Section 25532(a)should I store or handle hazardous a. 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 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 2 Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revolted. Owner or authorized agent: APPLICANT CERTIFICATION Date:5-18-2016 I certify that I have read this application and state that the above information is CON TRUCTTENDTNGAGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance 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, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. I understand my plans shall be used as public records. Licensed Signature Date 5-18-2016 Professional 3-Is- -Mv CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 CUP�RTINO (408)777-3228•FAX(408)777-3333•buildingCa�cupertino.org 13 �J/�� lJ ❑NEW CONSTRUCTION ❑ ADDITION ALTERATION/TI ❑ REVISION/DEFERRED ORIGIN PERMIT#� PROJECT ADDRE APN# • ,\ v OWNER NAME ` 1 yL'PHONE E-MAIL �i,� / �. STREET ADDRESS U�l`/� r _ X"' FAX v � I CONTACT NAME P. `O &MAIL v J r STREET ADDRE3 I MO'„D ❑OWNER ❑ OWNER-BUILDER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCIRTECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR!!! LICENSENUMBER LICBNSETYPE BUS.LIC COMPANYNAME E-MAIL FAX STREETADDRESS CITY,STATE,ZIP PHONE ARCHI 0gERN [ICENSENUMBER 92— BUS.LIC# COMPANY NAME r -MAIL FAX SIRE ADi� S CITY T RI d- PHONE{J 11a.' DESCRI' ON „en 9,nh � ��► I U r(IIJJ� V 1W pct . is Pl 3 . EXISTINGUSB PROPOSEDUSE CONSTR.TYPE #STORIES USE TYPE OCC. SQ.FT, VALUATION($) WaSTG NEW FLOOR DEMO TOTAL AREA AREA AREA NET AREA ' BATHROOM KITCHEN OTHER REMODELAREA REMODEL AREA REMODEL AREA PORCHAREA I DECK AREA J TOTALDECKIPORCHAREA GARAGE AREA: HDBTACH ATTACH #DWELUNGUNCIs: ISASFCONDUNIT []YES SECONDSTORY ❑YES BEING ADDED? ❑NO ADDITION? ❑NO PRE-APPLICATION [IVES IF YES,PROVDIE COPY OP IS T11E BLDG AN ❑X§&oCE TOTAL VALVA110Nr PLANNINGAPPL# []NO PLANNINGAPPROVALLE-1TE11 EICHLERHOM1IE? 7 By my signature below,I certify to each of the following: I a[ he property owner or authorized agent i act on pr�oA owner's behalf. IAve read this application and the information I have provid is correct. I h e read the Description of Work and verii sem. 1 agree to comply with all applicable local ordinances and state laws relating to buil g o t ction. I thorize representatives of Cupertino tortW �i¢enffi�tplgperly for inspection purposes. Signature of Applicant/Agent: Date: `(t/'I J SUPPLENTiNTA 1 AT1ON 15tMED PLAN CHECK TYPE ROUTING SLIP _New SFD or Multifamily dwellings: Apply for demolition permit for ❑ OVA THE COUNTER ❑ BUE LDINGPLANREVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW Commercial Bldgs: Provide a completed Hazardous Materials Disclosure [1STANDARD ❑ PUBLICWORKS fo_rm if any Hazardous Materials are being used as part of this project, ❑ LARGE ❑ FIRE DEPT _Copy of Planning Approval Letter or Meeting with Planning prior to ❑ MAJOR ❑ SAiLIITARY SEWER DISTRICT submittal of Building Permit application. ❑ ENVIRONMENTALH'EALTH �� No-ir-� 0-eA„ 1,J^d Lr^ n Bldg4pp 2011.docrevisedOG/21/11