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B-2017-0102 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMTT NO:B-2017-0102 10276 VIRGINIA SWAN PL CUPERTINO,CA 95014-2025(316 46 003) GAGNE BROTHERS ENTERPRISES INC NOVATO,CA 94949 OWNER'SNAME: MIYAMOTOJUDITHATRUSTEE DATE ISSUED:01/19/2017 OWNER'S PHONE:408-505-0700 PHONE NO:(415)506-0400 LICENSED CONTRACTOR'S DECLARATION BUILDING PERNHT INFO: License Class A:C-36 Lic.#857357 Contractor GAGNE BROTHERS ENTERPRISES INCDate 04/30/2017 X BLDG _ELECT X PLUMB MECH X RESIDENTIAL COMMERCLAL 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: I hereby affirm under penalty of perjury one of the following two declarations: (N)50 GAL WATER HEATER-SAME LOCATION 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 N 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:$3100.00 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 state laws relating to building construction,and hereby authorize 316 46 003 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 against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code_Se 8. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 1119/2017 Issued by:Abby Ayendg Date:01/19/2017 OWNER-BUILDER DEGI�r�IQN I hereby affirm that I am exempt from the Contractor's License Law for one of the RF-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 of Applicant: contractors to construct the project(Scc.7044,Business&Professions Code). Date:1/19/2017 1 hereby affirm under penalty of perjury one of the following three declarations: AT 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. 1 will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 8. I 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 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 Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,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: 1/19/2017 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 I hereby affirm that there is a cons uc ion 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. Licensed Signature Date 1/19/2017 Professional YD-Zola-- U O'l GENERAL PERMIT APPLICATION MEP COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE-CUPERTINO, CA 95014-3255 misc 1�1 1 1 1'IIINt (408)777-3228•FAX(408)777-3333•buildinpCWcupertino.orq PLUMBING E3NMCHANICAL ELECTRICAL EINEscELLANEous PROJECT ADDRESS /ry 7� J I-K(Si ` 14 5tJA-J OWNERNAME J,_ J'1 � PHONE °�� °®P E-MAIL STREET ADDRESS A'9L M 0�Cb ��r Y ' CITY,STATE,ZIP gAJ{ CONTACT NAME JEFF RAINEY PHONE 510-427-4260 E-MAIL jeffrey.rainey@aft.net STREETADDRESS 1069 EDGEMERE LANE CITY,STATE,ZIP HAYWARD, CA 945454 FAX510-783-1041 ❑OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT ❑ CONTRACTOR C4 CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACTOR NAME J +Z A.I(1W LICENSE NUMBER 857357 LICENSE TYPE A,C36 BUS.LIC# 3( (4 j q CowANYNAME BENJAMIN FRANKLIN PLUMBING E-MAIL FAX 415-506-04`10 STREETADDRESS 22 DIGITAL DR., STE 1 CITY STATE,ZIP NOVATO, CA 94949 PHONE 415-506-0410 ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC# COMPANY NAME E-MAIL FAX STREET ADDRESS CITY,STATE,ZIP PHONE USE OF SFD or DUPLEX ❑ MULTI-FAMILY PROJECT IN W IDLAND ❑ YES PROJECT IN ❑YES IS THE BLDG AN ❑YES BUILDING- ❑COMMERCIAL URBANINTERFACEAREA ❑ NO FLOODZONE ❑NO EICHLERHOME? ❑NO DESCRIPTION OF WORK ( _� kte/k roz u TOTAL VALUATION_ RECEIVED I By my signature below,I certify to each oY 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 for inspection purposes. Signature of Applicant(Agent: Date: S CEENT5,RqrO REQUIRED o :Us ON �. � ©x cv�R ac'oUVTIiR ' � I� iEXPItI"SS � EJ STANDARD y - Cl LARGE MAJt3R MEPMiscApp 201 Ldoc revised 06121111