B-2018.0928 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0928
10815 NORTHVIEW SQ CUPERTINO,CA 95014-0541(316 36 013) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME:PUNNOLI GOPAKUMAR AND DEVADASAN INDULEKHA T DATE ISSUED:05/30/2018
OWNER'S PHONE:312-613-004 PHONE NO:(415)7634002
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#857357
Contractor GAGNE BROTHERS ENTERPRISES INC Date 04/3012019 X BLDG_ELECT X PLUMB
1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTTAL COMMERCIAL
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REPLACE WATER HEATER 40 GAL(SAME LOCATION)
1 hereby affirm under penalty of perjury one of the following two declarations:
r. I have and will maintain a certificate of consent to self-insure far 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 It sura..,as provided for by
action 3700 of the Labor Code,for the perfornsunce ofthe work for which this
permit is issued. Sq.Ft Floor Arca: Valuation:$2600.00
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 stale laws relating to building construction,and hereby authorize 31636 013
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 Cupe Iiabiiities•judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accru against said y in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Addition.yL
the applicanl u derstands and will comply with all non-point
sourcper the pertinoMunicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
ur' Date 05-30-2018 Issued by:Kim Dunbar
Date:05/30/2018
DC LARAT O
I hereby affirm that 1 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.Ira roof is
t. 1,as owner ofthe property,ca my employees with wages as their sole installed without first obtaining au inspection,I agree to remove all new materials for
ompensation,will do the work,and the structure unto intended or offered for inspection.
sale(See.7044,Business&Professions Code)
z, 1,as owner ofthe property,am exclusively contracting with licensed Signature o£ApplicanC
contractors to consuvct the project(Sea7044,Business&Professions Code), Date:05-30-2018
1 hereby affirm under penalty of perjury one ofthe following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"Oil BETTER
u 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 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 ofthe 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 Muntclpal Code,Chapter 9.12 and the
a. 1 certify that in the performunce of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store o-handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
Worker's Compensation laws of California.If,after making this certificate of, air contaminants as defined by the Bay Area Air Quality Management District 1
P g will maintaincompliance with the rper m cipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health 8,Safety e,Sections 25 r 5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked, - Owner or authorized ag t:
APPLICANT CERTIFICATION Date:05-30-2018
I certify that I have read this application and slate 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.)
toenter 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, 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
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 05-30-2018 Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228• building@cupertino.org PEMIT4B- � mzg
CUPERTINO REV# DEE#
❑NEW CONSTRUCTION ❑ADDTPION ❑ALTERATION❑T.I. ❑MEP ❑RE-ROOF ❑SWEVMNG POOL/SPA
PROIECTADDRESSAPN# 3( 6
6 IS- 'll'1 �'eUJ' s�. � -3c�
OWNERNAME I PHONE E-MAIL
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STREET ADDRESSc pp CITY,STATE,ZIP
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CONTRACTOR NAME DOWNER-BUILDER COMPANY NAME LICENSENUMBER LICENSE TYPE
STREET ADDRESS _ CITY,STATE,ZIP V Y
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E-MAIL 2 PHONi�-TL4��(f
El ARCHITECT El OWNER[]OWNER AGENT CONTRACTOOCnR AGENT El ENGINEER El DEVELOPER❑TENANT
CONTACT NAME n H-MAIL
STREET ADDRESS Q\V/Jl CITY,STATE,ZIP PFIONE
DESCRIPTON
[#SINGLF-FAMRLY/DUPLEX ❑MULTI-FAMILY []INDUSTRIAL []COMMERCIAL
EXISTING USE RMSTINGSE NEWFLOORSF PORCHSF DECKSN DEMOSP STORIES# TOTALNETSF USE TYPE OCC SQ.FT. VALUATION(�)
REMODEL REMODEL KITCHEN REMODEL OTTER GARAGE []ATTACHED
BATHROOM SF SP SF SF []DETACHED
EXISING ❑YES EICHLER []YES -C.-US
ECOND S'rORYADDITION ❑YES
FIRE SPRINKLERS NO [:]NO []NU
DWELLING SECONDDWELLING []YES E]ATTACHED[]DETACHED OTHER
UNITS p UNIT ADD]TOM []NO S F
POOL$ ❑FIBERGLASS []VINYILINRD []GUNITE []PREFABRICATED
POOL-SP SEA-SF SPA ATcACFIRD Ll MS ❑NO I TOTAL-SF
REC V - -: T�fl V�UATION:
Cmnniercirti or Mniti-Fmriilu IIuildin¢s zvilh RrLlic Smirnmine Pvvls requires DepnrtnieU ofEzm lento!Henle mr rrvuul l/.l_C
RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF[_]ASPHALT SHINGLES[-]WOOD SHAKES E]WOODSHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IP NO PLYWOOD El L" El 3/8" PLYWOOD TYPE: PITCH: ROOF CLASS
YES 1#OF1N LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑COX OTHER •12' A
PROPOSED ROOF TYPE:DBIMUE-UPROOP 1]ASPHALTSHINGLES❑WOODSHAKES❑WOODsHiNGLES❑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 local ordinances and state laws relating to building construction, I authorize representatives of Cupertino to
enter the above-identified property fn r ttrposes. I acknowledge and authorize all information contained on this application form
to be made available for public- rd. ,! n
Signature of Applicant/Agent. Date: (J
SUPPLEMENTAL INFORMATIO UIRED
*New SFU/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new consnvcBruc
*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