B-2017-1689 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1689
10060 SCENIC BLVD CUPERTINO,CA 95014-2748(357 09 042) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME: SCHIAVONE DEAN PAND CATHERINE A DATE ISSUED:09/28/2017
OWNER'S PHONE:408-802-4095 PHONE NO:(415)763-4002
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36:A Lic.#857357
Contractor GAGNE BROTHERS ENTERPRISES INC Date 04/30/2019 X BLDG _ELECT X PLUMB
MECH X RESIDENTIAL_COMMERCIAL
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:
REPLACE WATER MAIN SERVICE
I 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 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:$4900.00
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 357 09 042
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 at t said'City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additional the apolicant understands and will comply with all non-point
source r-gulations pier the Cupertino M •icipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. •
40041. attire Date 9/28/2017 Issued by:Abby Ayende
• Date:09/28/2017
0 'a UILDER DECLARATION
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 ownerof 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:
contractor's to construct the project(Sec.7044,Business&Professions Code), Date:9/28/2017
I hereby affirm under penalty of perjury one of the following three declarations: 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
Cornpensation,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 Laboi'Code,for the performance of the 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
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 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 ea Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance wit a Cuperti o Municipal Code,Chapter 9.12 and
exemption,'I become subject to the Worker's Compensation provisions of the the Health&Saf y Code,Sectio 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall kf'
be deemed ievokad. Owner or authorized agen
APPLICANT CERTIFICATION Date:9/28/2017
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
consequenceiof th''e 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,
ECLARATION Code,Section 9.18: ' I understand my plans shall be used as public records.
Licensed
Signature Date 9/28/2017
Professional
•
CONSTRUCTION PERMIT APPLICATION
•
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
(":0 10300 TORRE AVENUE • CUPERTINO,CA 95014-3255
SK.19ss a o [9- I Wci
(408) 777-3228 • building@cupertino.org PEMIT#B- -
CUPERTINO REV# DEF#
. ❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.I. ❑MEP ❑RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRF r r `Y p r.� �-— cC 1 \id APN# 35 Oq,...0 Li 7_
OWNER NAME (�^J(v'\ vim'4�/`(lL EHO `J'&MAIL I
-4n aim ia\One.
STREETDDRESS CITY, STATE,ZIP
CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
el0 cne C�-�� r n l i oNS 4 � -'--J-`3C--1 30
ISTREET A RESS ' �_ t on_ q I
E-MAIL PHONE BUS.LIC#
. L-e0 C Ccaq g--1 (
❑ARCHITECT ❑OWNER(❑l OWWNER\AGGEEN'E,LE CONNNTRACTORAGENT❑ENGINEER�EE ❑DEVELOPER
0 TENANT( t^ (r� I '�,{ /�y.�,�
CONTACT c V .'e 1.V�J Y `^G� E-MAIL 'V V�Y 1 ct,_%c I3 )i-1 l kt i n f l'/11 c cc v 1
STREET ADDRESSHO
y€ �i/�/`QJ CITY,STATE,ZIP '' PLg ' � � VVV
DECRIPTO N jr_ ��✓�`/ n j p V\� 1 Y �E_ l _ °I� o GSC �� �. �\ '
p�\J '1 �.j�L >/T1`�JJ 1 �11J V1lJ �¢?��
❑SINGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES# TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION($)
,
REMODEL REMODEL KITCHEN REMODEL OTHR GARAGE 0 ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
II EXISING ❑YES EICHLER ElYES SECOND STORY ADDITION DYES
i FIRE SPRINKLERS 0 NO ❑ NO, ❑NO
iItDWELLING SECOND DWELLING 0 YES;❑ATTACHED El DETACHED OTHER
UNITS# UNIT ADDITON:' ❑NO: S F
POOLS! ❑FIBERGLASS'❑VINYL-LINED, 0 GUNITE 0 PREFABRICATED ,
POOL-SF SPA-SF' ' .I SPA ATTACHED DYES 0 NO I TOTAL-SF
RECEI�BY: �/�7 T TAL{VALUATION:
Commercial or Multi-Family Buildings with'Public Swimming Pools requires Department of Environmental Heath approval V` i % vJ._ / 0 f1r on
, RE-ROOFI EXISTING ROOF TYPE:: ❑BUILT-UP ROOF❑ASPHALT SHINGLES ET WOOD SHAKES❑WOOD SHINGLEStII TILLEEM//OTTHE/R(SPECIFY)
REMOVE
—i_L t/\J
REMOVE/REPLACE❑NO 'IF NO PLYWOOD ❑'h" ❑3/8" PLYWOOD TYPE: PITCH: ., ROOF CLASS
ElYEs I'#OF'LAYERS THICKNESS III 5/8" OTHER 111 OSB Li CDX OTHER 2 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES❑WOOD SHINGLES 0 OTHER
*Provide a signed copy of the,Cupertino's Tear-Off Policy SF #of SQUARES
By my signature below I certify to:each of 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 info ...ion 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 :I •roan :s ands : k.ws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified proper for inspeido p ;�aose• I acknowledge and authorize all information contained on this application form
to be made available for publi efor•
Signature of Applicant/Agent: Date: q. f `.
• SUPPLEMENTAL INFORMATI•1'R P d IRED
*New SFD/Second Dwelling,Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new construction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
*Copy of Planning Approval Letter of Meeting with Planning prior to submittal of Building Permit application.
*HOA-Provide a letter of approval from,the Home Owner's Association
BldgApp_2017.doc revised 08/01/17