B-2018-1335 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1335
21044 HAZ.ELBROOK OR CUPERTINO,CA 95014-1629(326 55 034) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME: DATE ISSUED:08/08/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#857357 X BLDG—ELECT X PLUMB
Contractor GAGNE BROTHERS ENTERPRISES INC Dale 04/30/2019 —
I hereby afilrm that I are licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of fine Business&Professions Code and that my
Become is in full force and effect. JOB DESCRIPTION:
REPLACE 50 GAL WATER HEATER(SAME LOCATION)
I hereby affirm under penaltyof perjury one of the following two dectnratimee
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. -
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permit is issued. Sq.Rt Floor Area: Valuation:$2400.00
APPLICANT CERT FICATION
I certify that I have read this application and state that the above
informallon 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 326 55 034
representatives of thiscity 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,casts,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against sald Cityln consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the appt�nt unde3 ads and will comply with all non-point
sourc?regulatrolrs per the Cupertin Munlclpal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
I hereby afilrm that I not exempt from the Contractor's License Law far its of the RE-ROOFS:
following two reasons: - All roofs shall be inspected prior to any rooting material being installed.Na rootis
r. 1,as owner of the property,or my employees with wages as their sole nstalled without first obtaining an inspection,I agree to remove all new matmials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Ino.k.ions Code)
x. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Cade). Date,8-8-2018
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 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 Imre rdous 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,Sectiuns 25505,25533,and 25534.1 will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 tied the
a I certify that in the performance of the work for which[his permit is issued,i health&Safety Code,Section 25532(a)should 1 store a-handle hazardous
shall not employ any person in any manner so as to become subject to dee 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,atter making this certificate or will umintaln compliance with the Cupertino Municipal Cade,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:8-8-2018
1 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 complyvSith all nbn oint source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,
Dale 8-8-20 8 License9 Professi