B-2017-2039 CITY OF CUPERTINO BUILDING PERMIT •
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-2039
21947 SHATTUCK DR CUPERTINO,CA 95014-4791(356 14 009) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME: BAUMAN HOWARD AND MARY J TRUSTEE DATE ISSUED: 11/28/2017
OWNER'S PHONE:408-250-1757 PHONE-NO:(415)763-4002
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-36 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 SERVICE FROM METER TO HOUSE-PRIVATE
I hereby affirm under penalty of perjury one of the following two declarations: PROPERTY
• 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.
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. Sq.Ft Floor Area: . Valuation:$9200.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
information is correct. agree to comply with all city and county ordinances APN Number: Occupancy Type:
I
and state laws relating to building construction,and hereby authorize 356 14 009
representatives of this city to enter upon the above mentioned property for ,
inspeetioh: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.�.lidant understands and will comply with all non-point
source regul. ions 0er,the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signal ' Date U 1 z Issued by:Kim Dunbar
Date: 11/28/2017
OWNER'BUILDER DECLARATION
i
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
t. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agreeto 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:
i• .' contractors to construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
. i. i 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
I Section 3700 of the Labor 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
3. 1 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
, I shall not employ any persondn 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 Co' "ections 25505,25533,and 25534.
�Labor Code',I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent ,r'1 h'
..
!APPLICANT CERTIFICATION Date: '
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.,l'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 ' , i ' I understand my plans shall be used as public records.
1i
. Licensed
Signatuie' Date Professional
I •
•
1
I .
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
. ....„ a' 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 •
„�z.f,,r0 408 777-3228 • build.in . )n��
( ) -:cupertino.org PEMIT 4B-�
CUPERTINO REVS' DEFE
❑ NEW CONSTRUCTION E ADDITION ❑ALTERATION ❑T.I. ❑MEP E RE-ROOF ❑SWIMMING POOL/SPA
PROJECT ADDRES,S� \ci '4 c�/� c J 6. t APN�5� i q
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OWNER NAME f_\( t) try) �d L„f , PHPNE 1 V� �� E-MAIL
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STREET ADDRESS I CITY, STATE,ZIP)EPCONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME J LICENSE NUMBER LICENSE TYPE
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❑ARCHITECT 0 OWNER.0 OWNER AGENT 0 CONTRACTOR AGENT❑ENGINEER❑DEVELOPER 0 TENANT
•
CONTACT NAME n E-MAIL
STREET ADDRESS 1��60
/// CITY,STATE,ZIP PHONE
DECRIPTON ateyssew
•
•
INGLE-FAMILY/DUPLEX ❑MULTI-FAMILY ❑INDUSTRIAL ❑COMMERCIAL
X 15
TING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES x TOTAL NET 5F
USE TYPE OCC SQ.FT. VALUAT•
ION(5) I
REMODEL REMODEL KITCHEN REMODEL OTHR ' GARAGE 0 ATTACHED
BATHROOM SF SF SF SF ❑DETACHED
EXISING ❑YES. EICHLER ❑ YES SECOND STORY ADDITION D YES •
FIRE SPRINKLERS 0 NO ❑ NO ❑NO
DWELLING SECOND DWELLING ❑yEs ❑ATTACHED DETACHED OTHER
UNITSx UNITADDITON: 0 N 5F
POOLS 0 FIBERGLASS ❑VINYL-LINED ❑GUNITE D PREFABRICATED
POOL-SF SPA:SF I SPA ATTACHED❑YES 0 NO I TOTAL-SF
RECE) `• ITIALZA8,60N:
Commercial m•Mu(li-Fnmilu Buildings with Public Ssvinnninq Pools remrires Deanrlmen t of Environmental Heath Immo-nal fi'gp'' /�`..RE-ROOF EXISTING ROOF TYPE: ❑BUILT-UP ROOF❑ASPHALT SHINGLES❑WOOD SHAKES❑WOO.SHINGLES❑TILE OTHER(SPECIFY)
REMOVE/REPLACE❑NO IF NO PLYWOOD 01" ❑3/B" PLYWOOD TYPE: PITCH: ROOF CLASS
0yE I OF LAYERS THICKNESS❑5/8" OTHER ❑OSB ❑CDX OTHER .12I A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES ❑WOOD SHAKES DWOOD 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 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 lo . • dinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified pr..erty for •nspection purposes. I acknowledge and authorize all information ontaine.-on this application form
to be made available for pubic record. -- fI i i
Signature of Applicant/Agent: --,I� Date: ►l• r
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Ivlultifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new constriction.
*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 or 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