12090126 !CITY.,OF CU•PEItT NO BUILDING PERMIT:,
BUILDING ADDRESS': 20325,S•hL,VENS CRL:CK,13l;V[)'(ALL) C'ON"1'RAC-i"OR:3 SNF TWORK, ; PE RiVlll \n: 1209012E
"OWN ER'.S''NA,NlE; W D V i'ROPERTif'S 260110'['ONVNE:CE N.'I'RE,DR-S'I•E;'230 DA"I;E, ISSUED--03'7291201 1
OWNEWS,PHONEi,9252886733: FOOTII11,1,RA'V`Gld;CiN 92610, P110NE:N0:(408)499-,3347 .
Z ,LICEN'SED"COXrRACFOR'S DECLARATION . ' _
BUiL_DiNG PERM1141NI.P , BLDG 1 LE'CF LUMB,
License Class:. Lic,# _
6 MECH'� R'ESiDEN:TiAt COMMERCIAL
Contractor C�.YL 1L'Date j
JO DESCRIPTION
I;herby.afirm hat am licensed under the pritrsrons of,ChaZ ter) n10m1v lxls 1Nc =vo3n SI f t p n"C.it l tv,
MODi1)CATION INCL UDi S"l;l1l Ri NtOVAI.Ofa6 EXISTING
-(commencing with,Sect)on 7000)ofDi'vision 3 of,thc,l36&mess,&Professions PANLI:.ANTENNAS FROM i'I'll ftOOf'fOP ANDIINS I ALI:.INGe6
Citdc and that my license is in full foree'andcffcct.
i,,hc'reby'arrirm udder'penalty'ofperjury one of the followi'i1g_two%declarations:
i;haye and will maintain a certH.1cate of'conseit to sell=insure for,Workers.
Compensation,as provided lor.by Section 31700 of tlie.L-.abor Codc;.foi',tlie
perfgrmance ofithe workTorwhieh tliis'permit is issued.
I have:and Will maintain Worker's Compensation Insurance;-a—provided 1'6rby ;
Se�tiorr3700 0l tlic.Labor'Codc,for the perforniance ofthe wcrk_for•whichA is S,q'.,Ft 1 loor:Nrca: Valuation $3500'
permit is issued.
APPLICANT CERCIFICA'CION APN NNuInber:,,316260y0 00 Occupancy Type.
Lcerti'fytthat I have read this app1icati(nwand,state-that tlic above inlbrnation'is
co(rect.,I agree;to comply,with all-!city and county ordinances°and state laws relating,
to„b iililing,',construction,and,hereby authorize representatives of this city to enter•
upon-Ahheaboyc iicntioned property for inspection purposes (Wc)agree to"save
PERMIT EXP-FRES IF' VORK.IS NOT S I'AR°fEl)
'i'ndemnify`and keep haniiless.the City'o1`Cuperuiio.a,,atnst liabilities,judgrnaiis:
,costs atnd,expenses which may accrue against said:City in consequcnce,'ofthe WITHIN-1$0 DAYS"OF PERMIT ISSUANCE. 11
Granting-of thusperiiiit. Additiofidly.the applicant understands and.will comply
180A)AVS=FROM LAST CALLED INSPECTION.
,with all non=point.so c regulations;per••thc CuperN10 Mimicipal Code•,Section -
.
•9.18.
.Issued by -
Signature, Date �6
❑
OWNER-BUILDER DECLARATION' ,
RE-ROOFS:
i,hereby affirm that I am exemptfrom'the�(gntracUir's License-I'."aw�for'nn'c'of All robfsrshall.be jnspcct-cd prior twiny,;roolmatcri'al;bcim)installed IN,roof'i•s
thc"folloWing twoycasons: instgillcd wiihoul'h sl.obt uning ati,inspection,I',agr` e;to remove all ncw•matcrials_l'6
I;as Qwger,of�the property,or my eni'ployees.%vith wag&5s,thcir,sofe''compcnsation, inspection.,
will do-the work,andalie?strueture isnot intended or,oflercd for s ile(Sec,704.4,, „
Mis ncss&Professions'-ode) Sigpaturc�of Applicant natcy
Inas owner of the property,am exclusively contracting withi,;licensed contractors°to _
construct the;project(Sec.7Q,44,E3usiness,&;,Professions Code):
NIA,ROQE Cn.A'E 121\GS TO
:BE.CLASS"it,'-OR BETTER
hereby affirm under penalty of perjury one of the f6ll6Wi11`g,1bree
d.eclaratioIts:
IIrV".'ARDOUS':NIA9 F,RIi*LS'DISCLOSURE
l liavc,and.`wi11 maintaiii`a Certilf ate of.Consentto,self-insure for Worker's --
Compensafion,as provided for by.,Section 3,7Mof'the labor Code,for•the I have read`the hazardous materials requircincnts uindcrChaptct 6 95,.of the
:performance-of the work;f&Wiich.tliis`permiCis issued. California I lealt_h&y'SaJet) C6dc,,Sccthm§2.565 24133 anda2i 34t1%4l maintaih
`I•havc7and will maintai'n`Worker's,Compcns-ation Insurance;asiproyided,lbr by compliance with the,Cupertinb Muiiieip it Codi;Chaptcr=9 I2ganclthe i161111&
jSection 3;700 of the Labor,Cod"c,.I'or�the,peil'd'niancc,of the4ork for, this
Safety Code Scctioit�25�32(a)_sh'ould I store or handle hazardousamateriil.
A-dditiomilly,shodid 1 useVeguipmeritxtr devices�whtch emit hazardous i
a " .
peribiuis issued: contaminants as def'ned by4he 13ay Arca Air Qualii,,Vlariagcmcnt District I"will
I'ccrfifythat inthe,performaneeof the wo'rk;lor,whiclfthis permit is issued,I shall m;t(ntain compliance vy ith the+Cupertino iN9tinicipal,Codc Cba'pter 9.12?_arid the
'not employ'�;any person m any manner so as to;bccome subject`,to the Worker's I lealih dr Safet Go e S_-ectionti 75505_255JIS and 21139. "
'C'ompensaiion laws offCaliloni_ia.'It"alternt tking`thts certificate of cacmptioir,.1
'become sulJ'ct to the Worker's Compensation provisions of the1Labor'C.'ode,I must 'Owner or,a r3ie;d�agent:, q
forthwith comply=with such provisions orthisrperrnit shal.l`betdcemed,revoked. (late:
APPI iCANT CERCIEICAI'IOV' CONS"I RhiG_I'10\ I:ENDhNG'AGE\Cl:
I cert ify"that,I havefread this application and state that tliCgabovcjnlorm�ation is +l hcicbVatfimi'that tl-icre:is&construciion,luidingo a2cncyfor the'jiCYTOnn inCCc5.l v i)rk'1s
correct,I a ree to comply with all tit and county'ordlnances and state,lairs relatim, for ttliibh this pear insissued Sec �Q9�7;C;n�C')
to building construction,„and hereby iLuthonrc repreacntaUves of this city to enter Lender's”. rine
upon the7above,mentioned property For.inspectton�purposes.;(We),agreeab save
indemnify,and keep harriless'thc City o1`;Cupertt 6 ainst,liabilities;jiidgnicnts, Leoder's,A_ddress
costs,and',cxpenses wliich:may^accf.uc against:`said City:in•consequcncc of the
granting ol(this permit.Additionally,the;apphcant Ciiid'crstandsand will comply CRCIII I LCiI S DECLARATION'
w"uh.,all tion-point source regulations pc�'tlicyCtpertin�Muni ipal:Coiv Scyljon
I unders(and,,my plans'shall 6c�uscd a&,pitblic rccords:,
signature' Date Licensed°Professional
CITY OF CUPERTINO'
FEE,ESTIMATOR BUILDING DIVISION
ADDRESS: 20325'•stvns cirk blvd: DATE:' 0911312012 REVIEWED.BY:. bob s:
APN: BP#: 'VALUATION; $3,500
,PERMIT TYPE_; Building Permit PLAN CHECKTYPE:. Altee.ation%Addition`/Repair
PRIMARY PENTAMATION
Commercial Building IGENGOM;
USE. PERMIT TYPE:
WORK �jthe'i
-, exisitih t-moile site.facilit . Modification includes the.removal,of6 existin panel antennas frorn
SCOPE , rooftop and installing 6 new panel antennas similar size.
Au a
R
�x .
41ec/;. !'Iran C'hec'k 1'lnmti. Pkrr')Check 1?lec::f?•'an(hrcle
Vicch. F'ernr{1•f ee,' Phimh, Permit Free: El�c;Nrnzit.Fee:
niher.,Wech.in, C)/lier Plurnli:Insr,; C)rlu�r 1:,le6_Insp.
l/eclat /n/�. f ee:- f'lun li. Ii'rsp.
El--L-
/Tce... Ldp`.Ins %tre.
NOTE: This esdmate.does.not'indude fees due io oiher:Departmenis(Le.Plann'ing,,Public Works,Fire,Sanitary°Sewer District,School.
District,eta), These ees are based on the relimina. °in ormdtidn-availahle.and are,bn! ,diitestiiridta Contact th'e-De t'or addns:.'1'iri o.
FEE ITEMS (Fee,Resolution 1.1-053Eft' FEE QTY/FEE MISC ITEMS
'Plan Check Fee: Hourly Only? 0 Yes: (F)No $0.004�,hours Plan Check,Hourly
Suppl. PCFee: (F) Reg. :(),'OT Q.p hrs. $0.00 -$'532.00,1ISTPLNOK
PMEPIan Check:, $0.00
Permit Fee: Hourly Only?' Yes (F),No. '$0.00
Suppl.'I'nsp.Fee:�'Reg., 0' 0;0, hrs $0.00
PME th it,Fee: -,$0.00
PME Permit Fee: $0.00
(.'cii�.fr r.rc;inn':Tczr: ,
911nii7Jstrai`i,b eFee:
Work Without.Permit? Y,esQ No $0:00'
Advanced-Planning Fee- $0.00 .hours Inspections 1 .
frelvel l')oculnentulion Fees.- $266.00 ISTINSP Inspection,Hourly
Strong Motion Fee: IBSEISMICO• $0.74 Select an Administrative Item,
Bldg Stds Commission F&-. IBCBSC $1.=00
SUBTOTALS• .74 $798.00 TOTLFEE: '$799.74
ffifa $1
a ;s? .
Revised: 07/01120.12