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B-2017-0215CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2017-0215 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 DATE ISSUED: 02/06/2017 OWNER'S PHONE: 408-446-2724 PHONE NO: (415) 506-0400 LICENSED CONTRA TOWS DECLARATION BUILDING PERMIT INFO: License Class A: C-36 Lie. 9B51U7 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: REPIPE SFD (ABS) - DRAIN I hereby affirm under penalty of perjury one of the following two declarations: i. 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. Sq. Ft Floor Area: Valuation: $11640.00 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 356 02 024 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. Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 2/6/2017 Issued by: AbbyAyende OWNER -B iii D R DECLARATION Date: 02/06/2017 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 i. 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 (Scc.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: 2/6/2017 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER i. 1 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 ofthe work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the 3. 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 shall not employ any person in any manner so as to become subject to the 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, 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: 2/6/2017 I 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. Licensed Signature Date 2/6/2017 Professional GENERAL PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 • buildina(�cuperHno.org V0ht'Ln4BING nMECHANTC'AT. 7 T:TFr-rPT('AT F-1IfTCr'I:TT n=T TT PROJECT -ADDRESS ' Q^ Z , +� Dc,� APY �Z iJZ 011TIiERNTAME 1'I�nJ t\�/\7�`r► PH0NT (�(1�-�}E-MAIL s® " N _7ri �i'?►- STREET ADDRESS r CITY, STATE, ZIP �^ r-lj} FAX CONTACT NAME PHONE (1jTp� .. (j STREET ADDRESS � � � � CITY, STATE, ZIP � ! /'��, FAX ❑ OWNER ❑ OWNER -BUILDER ❑ OWNTERAGENTT )§COr'TRACTOR ❑CONTRACTORAGEN'T ❑ iARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENA'N'T CONTRACTOR NAME a� p� _ LICENSE NTLWBER �+? 5+�- L CEI�TSE T1YE�w .y sj % ! " G� BUS, LIC" Vit "f COMPANY NAME �e1 o K� 1_,1U4� 01 Vsl rl EMarr- FAX 1 STREET ADDRESS G� CITY, STATE, ZIP C* `W PHON ARCHITECT/ENGINEERNAA4E LICENSE NUMBER BUS. LI/C(0 COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP I 0 PHONE USE OF SFD orDL-,PLEX ❑ MULTI-FA10LY PROJECT LN AMDLAND ❑ 17-S PROSECT ❑ YES BTJII..DAG:. I UMAN INTERFACE AREA ❑. NO I FLOOD z NE ❑ No .. IS THF BLDG AN ❑ 1'BS EICHLER HOME? ❑ NO DESCRIPTION CFVdOF.K i G c TOTAL VALUATION:tit ��yy V\,/ RECEIV'}� By my signature below, I certify to each of the following: I am the property owner or authorized agent to acl on the property ov er's bAralf. I have read this application and the nlfonnation 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 lawsrelating t uilding construction- 1 authorize representatives of Cupertino to enter fie above -den *fled property for inspection purposes. Signature of Applicant/Agent: Date:: �TJPPLEMENTAL INFORMATION REQUIRED i of _ CE,$E�1Vil.< ' U z ' ❑- 1vZAJOR A7EPA1j'iscApp_2011.doc revised 06/21/11