15090027CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10655 MARY AVE CZvTRA O Sr�� fCpr PERMIT NO: 15090027
OWNER'S NAME: CUPERTINO LOC-N-STOR LLC 4.0 , � 1 V -0\1
Z � )c, rte[ t"V ff DATE ISSUED: 09/10/2015
OWNER'S PHONE: 9164439400 \, f•� Z �j I PHONE NO:
P LICENSED CONTRACTOR'S DECLARATIO
License Class ` – �0 Lic. # Z
Contractor Date f to
I hereby affirm th 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
tion 3700 of the Labor Code, for the performance 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 soullt regulations per the Cupertino Municipal Code, Section 9.18.
Signature_ Date '?- rVjJ
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
t. I, 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:
i. 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 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 ❑
AT&T - ON (E) CELL TOWER, SWAP OUT ANTENNAS (3),
ADD RRU'S, FIBER BOXES, ETC,.
Sq. Ft Floor Area: I Valuation: �I .�nno
APNNumber: 32606050.00 1Occupancc fcpe:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS 9FROM LAST CALLED INSPE/C� ION.
Issued by: if—Q l�E,i"'�`r 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 & Safety Code, Sections 25505, 25533, and 25534.
Own r aut ed agent:
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 Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
GUP_ERTINIO I (408) 777-3228 • FAX (408) 777-3333 • building(okupertino.org 1��GI/7O
NEW CONSTRUCTION ❑ ADDITION ❑ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT #
PROJECT ADDRESS 10655 Mary Avenue, Cupertino, CA
APN # 326-06-050
OWNER NAME
Cupertino Loc-N-Stor, LLC.
PHONE/I/\
L( V
E-MAn,
STREET ADDRESS P.O. Box 1166
CITY, STATE, ZIP Point Reyes Station, CA 94956
FAX
CONTACT NAME Austin Ching on behalf of AT&T mobility
PHONE 808-282-3006
E-MAIL austin.ching@ericsson.com
STREET ADDRESS 6140 Stoneridge Mall Dr., 3rd Floor
CITY, STATE, ZIP Pleasanton, CA T;AX
925-416-0219
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ® TENANT
CONTRACTOR NAME tbd
LICENSE NUMBER
LICENSE TYPE
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
ARCHITECT/ENGINEER NAME Sohail Shah
LICENSE NUMBER 0216
BUS. LIC #
COMPANY NAME pDC Corporation
E-MAIL paulo@pdccorp.net
FAX 925-606-5868
STREET ADDRESS 1062 Concannon Blvd.
CITY, STATE, ZIP Livermore, CA 94550
PHONE 510-385-5541
DESCRIPTION OF WORK Swap (3) antennas; add (3) new RRU-1 Is and (3) new RRU-12s with A2 Modules; add(]) new DC -6 fiber/power squid; add (3) new fiber
excess boxes; add (1) new fiber/power conduit inside ofexisting monopole; add (1) DUS-41 inside existing 19" rack; removal of(]8) 7/8" coax lines
EXISTING USE
PROPOSED USE CONSTR.
TYPE
# STORIES
wireless facility
same
1 USE TYPE
OCC.
SQ.FT.
VALUATION (S)
EXISTG
NEW FLOOR
DEMO n/a
TOTAL
AREA 207}
AREA n/a
AREA
NET AREA
BATHROOM KITCHEN
REMODEL AREA n/a REMODEL AREA n/a
OTHER
REMODEL AREA D/a
PORCH AREA
DECK AREA
TOTAL DECK/PORCH AREA
GARAGE AREA: DETACH
n/a
n/a
I
n/a
I n/a ❑ ATTACH
0 DWELLING UNITS:
IS A SECOND UNIT []YES
SECOND STORY
n/a
BEING ADDED? ®NO
ADDITION? NO \
PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF
IS THE BLDG AN ❑ YES EI
TOTAL VALUATION:
PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER
EICHLER HOME? ®NO
$15,000
By my signature below, I certify to each of the following: I am the pr owner or su Izedt10 a property owner's behalf. 1 have read this
application and the information I have provided is correct. I have read the Description of Work and accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construction, JeathUrbWepresentatives of Cupertino to enter the above-idenlified property for inspection purposes.
Signature of Applicant/Agent: Date: j
SUPPLEMENTAL INFORMATION REQUIRED
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ BUILDING PLAN REVIEW
New SFD or Multifamily dwellings: Apply for demolition permit for
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
❑ 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 prior to
1-1MAJOR
ElSANITARY SEWER DISTRICT
submittal of Building Permit application.
❑ ENVIRONMENTAL HEALTH
B1dgApp_2011.doc revised 06/21/11
CITY OF CUPERTINO
j� FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addil7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
ADDRESS: 10655 MARY AVE
DATE: 09/03/2015
REVIEWED BY: MELISSA
APN: 326 06 050
BP#:
*VALUATION: 1$15,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration /Addition/ Repair
PRIMARY
Commercial Building
USE
Civil / Religious activities
in BQ zone? Yes � No
PENTAMATION
PERMIT TYPE: TELECOMFAC
WORK
AT&T - ON E CELL TOWER, SWAP OUT ANTENNAS (3), ADD RRU'S, FIBER BOXES, ETC,.
SCOPE
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addil7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
ch. Pi
QTY/FEE
I''�n:
ly/dtmhi P rmirFt'e.
Fslec. hermir 1'-'-.-.
,P
<ifec . AspEl
trrnb Lr,arJ.
Cit er.t tz r. insp,
Suppl. PC Fee: Q Reg. () OT0.0
hrs
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc.). These fees are based on the preliminary information available and are only an estimate. Contact the Dept for addil7 info.
FEE ITEMS (Fee Resolution 11-053 Eff. 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
Select a Misc Bldg/Structure
or Element of a Building
Suppl. PC Fee: Q Reg. () OT0.0
hrs
$0.00
PME Plan Check:
$0.00
Pen -nit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT0.0
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
Construction Tax: 1BCONSTAxC
$0.00
G
Work Without Permit? Yes No
$0.00
Advanced Planning Fee:
$0.00
0 #
$1,145.00
Antenna - Telecom Facility
IANTCELFRE Cellular, Free -Standing
®�
Strong Motion Fee. IBSEISMICO
$4.20
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS: 1
$5.201$1,145.00
TOTAL FEE:
$1,150.20
Revised: 07/02/2015
1
Building Department
City Of Cupertino
10300 Torre Avenue
is Cupertino, CA 95014-3255
Telephone: 408-777-3228
CUPERTINO Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: 10655Mary Ave
MT # 15090027
OWNER'S NAME:Cupertino Loc-N-Stor
PHONE # 916-443-9400
GENERALCONTRACTOR: CBA Site Services
BUSINESS LICENSE # 455726
ADDRESS: 75 Lauritzen Lane
CITY/ZIPCODE: Oakley, CA 9461
`Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCC i NCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL, CONTRACT RI;AVOBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
SignatuDate
Please check applicable subcontractors and complete the following information:
V
SUBCONTP--kCTOR
BUSINESS NAME
BUSINESS LICENSE #
--Cabinets
& Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring 1' Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
--Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
actor Signature
Date