B-2017-2149 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2149
10130 BUBB RD CUPERTINO,CA 95014-4132(357 20 023) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME: CALIFORNIA STATE OF DATE"ISSUED: 12/14/2017
OWNER'S PHONE:408-590-7553 PHONE NO:(415)7634002
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO'
License Class A.C-36 Lic.#857357
Contractor GAGNE BROTHERS ENTERPRISES INC Date 04/30/2019 X BLDG _ELECT X 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
CALTRANS-REPLACE 4 GAL WATER HEATER
I hereby affirm under penalty of perjury one of the following two declarations:
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.
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:$2754.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN Number Occupancy Type:
information is correct.I agree to comply with all city and county ordinances 357 20 023
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue -•- said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionall the apple,.nt understands and will comply with all non-point
source reg lations per e Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION
ignature " 1 Date 12/14/2017 Issued by Abby Ayende
Date: 12/14/2017
dim . 11 r.�._t .-.s .1,
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 roofmg material being installed.If a roof is
i. 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:12/14/2017
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
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
s. I certify that in the performance of the work for which this permit is issued,I material.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the :— -• Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with e Cupertino i unicipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Saf Co • ections .505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized a' e t:
APPLICANT CERTIFICATION Date:12/14/2017
T t leAn,c0 _ENDIN A N -
Icertify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance
correct.I agree to comply with all city and county ordinances and state laws of work's for which this permit is issued(Sec.3097,Civ C.)
relating to building construction,and hereby authorize representatives of this city Lender's Name
to enter upon the above mentioned property for inspection purposes. (We)agree
to save indemnify and keep harmless the City of Cupertino against liabilities,
Lender's Address
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands ARCHITECT'S AECLARATION
and will comply with all non-point source regulations per the Cupertino Municipal I understand my plans shall be used as public records.
Code,Section 9.18.
Licensed
Signature - Date 12/14/2017 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO,CA 95014-3255 { p/ (may
s (408)777-3228 • building@cupertino.org PEMIT#B- V C: 1 _' 31
CUPERTINO REV# DEF#
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION❑T.I. LI MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRES 1 0 V C I APN# , �-� o n5
OWNER NAM ,tra(r}3 /Jci
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EMASTREET ADDRESS C�hCITY,STATE,ZIP
CONTRACTOR NAME ElOWNER-BUILDERCOMPANY NAME LICENSE NUMBER LICENSE TYPE
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0 ARCHITECT 0 OWNER 0 OWNER AGENT 0 COWRACTORAGENT❑ENGINEER 0 DEVELOPER 0 TENANT
CONTA E-MAIL
STREET ADDRESS CITY,STATE,ZIP O
DESCRWTON a�v\1lO 6 ' W 1 \ .4'
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❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL 0 COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($) II
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING 0 YES EICHLER 0 YES SECOND STORY ADDITION ❑YES
FIRE SPRINKLERS❑NO ❑ NO 0 NO
DWELLING SECOND DWELLING ❑YES 0 ATTACHED D DETACHED OTHER.
UNITS# UNIT ADDITON: ❑NO S F
POOLS! 0 FIBERGLASS D VINYL-LINED ❑GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPA ATTACHED❑YES .❑NO I TOTAL-SF -
REY: TOTAiVA�UATION:
Commercial or Multi-Family Buildings with Public Swimming Pools requires Department of Environmental Heath approval j A Itw2�J('
RE-ROOF)EXISTING ROOF TYPE: DBUILT-UP ROOF 0 ASPHALT SHINGLES WOOD SHAKES Q WOOD SHIT'GLES 0 TILE OTHER(SPECIFY)
REMOVE/REPLACE Q NOI IF NO PLYWOOD 01" ❑3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
❑YEs #OF LAYERS THICKNESS❑5/8" OTHER ' ❑OSB ❑CDX OTHER ,2 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF DASPHALT SHINGLES 0 WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear-Off Policy SF #of SQUARES
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 lo ord ances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified pro - ty for' .pection purposes. I acknowledge and authorize all information contained on this application form
to be made available for pub' fid. 0
Signature of Applicant/Agen: -"' - Date:
a 1 0) ( i
SUPPLEMENTAL INFORMATI 6• QUIRED
"New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter or Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from the Home Owner's Association
BldgApp_2017.doc revised 08/01/17