B-2016-2480CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
10110 ADELHEID CT CUPERTINO, CA 95014-2722 (357 09 028)
CONTRACTOR:
GAGNE BROTHERS
PERMIT NO: B-2016-2480
ENTERPRISES INC
NOVATO, CA 94949
OWNER'S NAME: TRANKLE THOMAS L AND JANET L TRUSTEE
DATE ISSUED: 08/09/2016
OWNER'S PHONE: 408-446-1818
PHONE NO: (415) 506-0400
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C-36 Lic. #857357
Contractor -GAGNE BROTHERS ENTERPRISES INCDate 04/30/2017
X BLDG —ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH X RESIDENTIAL _ COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury oneof the following two declarations;
REPLACE WATER MAIN SERVICE
m. Viand 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.
42.
1 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: $4195.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
357 09 028
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue agai =aid City in consequence of the granting of this permit.
Additionally, - e appy cant understands and will comply with.all non-point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source re lations pier the Cu ertino Munic' Peode�"Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
,,Signature �,
9 Date 8/9/201$
.
Issued by. Abby Ae�nde
..Date:
OWNERA 1II D R DECLARATION
08/09/2016
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 roofing material being installed. If a roof is
1. 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 ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 8/9/2016
I hereby affirm under penalty of perjury one of the following three declarations:
m. I have and will maintain a Certificate of Consent to self-insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
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. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this permit is issued, I
Health & Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should ui Eqent or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined y the Bay Arch Air Quality Management District I
will maintain compliance Ndth the Cuper ' o Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safe Code, Se 'ons 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 9/2016
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 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.
Signature Date 8/9/2016
Licensed
Professional
GENERAL PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org
P-)- X010 -7-wo
MEP
MISC
PROJECT ADDRESS1 ��. �` � y C� APN # T Oq OW
OWNER NAME PHONE Il S
3' C° L-EAjEiZ 4Cg- 4 19is E-MAIL
STREET ADDRESS CITY, STATE, ZIP FAX
1C31 i O -A Clsot4
�CONTACT NAWPHONE _ E-MAIL
r7rs�ti
STREET ADDRESS nn
D\,el r 4N1L— J -J
14 l— 1 0%—JIInc) ft 14mvvr//
CITY, STATE, ZIP
� � C,A , i L
g%-,Dec%dV�'ilVVV4iV)
FAX �? ( ow o t VI7 j -0
❑ OWNER ❑ OWNER -BUILDER ❑ OWNERAGENT &CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONT n CTOR NAME
LIC NSE NUMBER �q
LpICENSE TYPE
BUS. LIC #
OMPANY N
&MAILa a •rFni �fIF-1��
FAX
STREET ADDRESS
CI SgqT^ATE,LIP
PHBOaNE rygg�g r�
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC #
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF '449 SFD Or Duplex ❑ Multi -Family
STRUCTURE: ❑ Commercial
PROJECT IN WILDLAND
URBAN INTERFACE AREA ❑ Yes 1i—N.
PROJECT IN
FLOOD ZONE ❑ Yes ❑ NO
DESCRIPTION OF WORK
W A, u
TOTAL VALUATION:
=4117J
By my signature below, certify to each of ollowing: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the inf enation I haveIded is correct. I have read the Description of Work and verify it is accurate. I agr e to comply with all applicable local
ordinances and state la s relat o building construction. I authorize representatives of Cupertino to enter the above- dentifi d rope rty for inspection purposes.
Signature ofApplicant/A Date:
SUPPLEMENTAL INFORMATION REQUIRED -
- - '? �hFFif`P ICF /M1NT U
MEPMiscApp_201 Ldoc Devised 03116111