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B-2017-1362 CITY OF CUPERTINO BUILDING PERMIT • BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1362 10900 N BLANEY AVE CUPERTINO,CA 95014-0599(316 03 045) SAC WIRELESS OF CA INC CHICAGO,IL 60661 OWNER'S NAME: PACIFIC GAS AND ELECTRIC CO DATE ISSUED:10/25/2017 OWNER'S PHONE:530-957-7935 PHONE NO:(312)809-8013 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#972144 Contractor SAC WIRELESS OF CA INC Date 04/30/2018 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: REPLACE EXISTING ANTENNAS(9);REPLACE RRUS;ADDITION I hereby affirm under penalty of perjury one of the following two declarations: OF RRUS;ADDITION OF ANCILLARY SUPPORT EQUIPMENT 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 ormance of the work for-which this permit is issued. I have and will maintain Worker's Compensation Insurance,as provided for by 19,Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$22000.00 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 316 03 045 representatives of this city to enter upon the above mentioned property for inspection purposes. (VVe)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';perthe Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. R Ognature Date 10/25/2017 Issued by:Abby Ayende Date: 10/25/2017 • 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 Oowner 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(Sec7044,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:10/25/2017 1 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 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. 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 permit is,issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I 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 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25 Labor Code,I must forthwith comply with such provisions or this permit shall _ be deemed revoked. P er or authorized agent: - - APPLICANT CERTIFICATION s ate:10/25/2017 I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY 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 10/25/2017 Professional \ / CONSTRUCTION PERMIT APPLICATION /' COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION /re. 10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 CUPERTINO (408)777-3228•FAX(408)777-3333•building aC)cupertino.orq ' 13(to 2, ❑NEW CONSTRUCTION ❑ ADDITION X ALTERATION/TI ❑ REVISION/DEFERRED ORIGINAL PERMIT it PROJECT ADDRESS 10900 N. Blaney Avenue APNB 316-03-045 OWNERNAME PG&E PHONE E-MAIL STREET ADDRESS 245 Market St.,Mail Code N100 CITY,STATE,ZIP San Francisco,CA 94105-1702FAX CONTACT NAME Gordon Bell for AT&T PRONE 530.957.7935 E-MAIL gbell@j5ip.com STREET ADDRESS 6000 Terras Path CITY,STATE,ZIP Placerville, CA 95667 FAX • D OWNER D OWNER-BUILDER ❑'OWNER AGENT ❑ CONTRACTOR CON[RACI'OR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT - CONTRACTOR NAME � � LICENSE NUM 44-2 Z 1 f I LICENSE T BUS.LIC N i tt 13Q�`�C-SS2 ((_��f `t COMPANY NAME E-MAIL FAX .1Pit— U) 1(ZE(.C2-75 S Ti tv.oi- -k ( _P2:x:SSC—Z_ ) 5'k -)' C- —\-- STREET ADDRESS CITY,STATE,ZIP PRO P. MI Golf-Ltx..) ?1-SS 2b \Ss) lir 3�0 cr,N)Loa ) GiA-. crui Zt 451-ga-7L 1117 ARCHITECT/ENGINEER NAME Leszek Krasuskl LICENSE NUMBER 71358 BUS.LIC# COMPANYNAMEd5 Infrastructure Partners E-MAIL Ikrasuski@j5ip.com FAX • STREET ADDRESS 200 Main Street,Ste. 100 CITY,sTATE,ZIP Irvine, CA 92614 PHONE 949.247.7767x112 DISCIUPI'ION OF WORK Modification of an existing cell including,but not limited to, removal and replacement of existing antennas, removal and replacement of existing RRUS, addition of RRUS,and addition of ancillary support equipment. See detailed project description attached and on Sheet T-1. EXISTING USE PROPOSED USE CONS E.TYPE If STORIES USE TYPE OCC. SQ.FT. VALUATION($) Utilities&Telecom Same as existing V-8 N/A < BXISfG NEW FLOOR ' DEMO TOTAL N/A AREA 240 s.f. AREA N/A AREA N/A NET AREA N/A Telecom U BATHROOM ' KITCHEN OTHER REMODEL AREA N/A REMODEL AREA N/A REMODEL AREA N/A PORCH AREA DECK AREA TOTAL DECK/PORCH AREA GARAGE AREA: 0 DETACH ❑ATTACH R DWELLING UNITS: IS ASECOND UNIT OYES SIICONDSTORY ❑YES BEING ADDED? 0 N ADDITION? 0 N PEE-APPLICATION ❑YES IF YES,PROVIDE COPY OF IS THE ELDG AN ❑YES •rRr V." '' TOTAL VALUATION: PLANNING.APPLP ONO PLANNING APPROVAL LETTER EICIILERHOME? ❑NO - $22,000 By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinanCes and state laws relating to b 'Ding const;„tion. I aut•o: e representative.''pertino to enter the above-identified roperty for_ inspection purposes. Signature of Applicant/Agent: G- •` ,:/�:e / o� _,.,-.._.„........--- SUPPLEMENTAL / . Date: ��Lo�T' SUPPLEMENTAL INFORMATION REQUIRED PLAN CHECK TYPE ROUTING SLIP New SFD or Multifamily dwellings: Apply for,demolition permit for ❑ OVER-THE COUNTER r BUILDING PLAN REVIEW existing building(s). Demolition permit is required prior to issuance of building permit for new building. D EXPRESS PLANNING PLAN REVIEW _Commercial Bldgs: Provide a completed Hazardous Materials Disclosure D STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ LARGE ❑ FIRE DEPT —Copy of Planning Approval Letter or Meeting with Planning priorto ❑ MAJOR 0 SANITARY SEWER AISTRICT submittal of Building Permit application. 0 ENVIRONMENTAL HEALTH BldgApp 2011,doc revised 06/21/11