B-2016-2896CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2016-2896
22283 N DE ANZA CIR CUPERTINO, CA 95014-3950 (356 02 024) GAGNE BROTHERS
ENTERPRISES INC
NOVATO, CA 94949
OWNER'S NAME: AUSTIN L SCOT AND DONNA M TRUSTEE I I DATE ISSUED: 10/11/2016
(OWNER'S PHONE: 408-446-2724 I I PHONE NO: (415) 506-0400
_�_ 1X9140 0114.1111g
License Class C;36 Lic. #25ZU7
Contractor GAGNE BROTHERS ENTERPRISES INCDate 04/30/2017
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.
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.
APPLICANT CERTIFICATION
certi that I have read this application and state that the above
information is correct. I agree to comply with all city and county ordinances
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
may accrue against said City in consequence of the granting of this permit.-
Additionally, the applicant understands and will comply with all n int
.
source regulations per the Cupertino Municipal Code, Se 9.18.
Date 10/11/2016
I hereby affirm that I aTx from the Contractor's License Law for one of the
following two reasons:
I, as owner of the property, or my employees with wages as their sole
compensation, will'do the work, and the structure is not intended or offered for
sale (Sec.7044, Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Scc.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three 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.
2. 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.
a. I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the
Worker's Compensation laws of California. If, after making this certificate of
exemption, I become subject to the Worker's Compensation provisions of the
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked.
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 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 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
Code, Section 9.18.
Signature Date 10/11/2016
BUILDING PERMIT INFO:
BLDG —ELECT X PLUMB
MEECH X RESIDENTIAL_ COMMERCIAL
DESCRIPTION:
,ACE 40 GAL WATER HEATER - SAME LOCATION
Sq. Ft Floor Area: I Valuation: $2300.00
APN Number: Occupancy Type:
356 02 024
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
by: Kim Dunbar
RE -ROOFS. -
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant:
Date: 10/11/2016
{t1W
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date: 10/11/2016
ION LY,
A E
hereby affirm that there is a constr on lendin cy for the performance
of work's for which this permit is is_ ipri t97., Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
Licensed
GENERAL PERMIT APPLICATION MEP
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 - building9cupertino.orq
MISC
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OWNERNAME D66v 1JJ 4 5-uA
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PHONE. ^�
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E-MAIL
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CITY, STATE, ZIP _ ?,>01
CCJ3L'-2-71,J6i G A / J 01 Lf
CONTACT NAME JEFF RAINEY
PHONE510-427-4260
E-MAIL
jeffrey.rainey@aft.net
STREET ADDRESS 1069'EDGEMERE LANE
CrTY,STATE, ZIP HAYWARD, CA 945454
FAX510-783-1041
❑ OWNER ❑. OWNER -BUILDER ❑ OWNER AGENT ❑ CONTRACTOR C4 CONTRACTOR AGENT ❑' ARCHITECT ❑ ENGINEER '❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
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LICENSE NUMBER
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ARCIRTECT/ENGINEER NAME
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STREET ADDRESS
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PHONE:
USE. OF SFD or DUPLEX ❑ muLTI-FAMII.Y
BUILDINGCOMMERCIAL
PROJECT IN WBDLAND ❑ YES TR70-CT71N
URBAN INTERFACE AREA ❑ NO
❑ YES
DNE ❑ NO
SS THE BLDG AN ❑ YES
EICHLERHONM9 Q NO
DESCRIPTION OF WORK ,j ` %or- y
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TOTAL VALUATION
RECEIVED Byf
By my Signature below, I certify to each of the following: I am the property owner or authorized e react on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description c and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building, construction. I authorize repr ves of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date: yO 1
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_ - SUPPL . ORNIATION D
OFFICE USE ONLY
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MEPMiscApp 2011.doc revised 06121111