B-2018-0927 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0927
6362 BLACKWOOD DR CUPERTINO,CA 95014-4617(369 17 051) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME:BURGETT ETHELS TRUSTEE&ET AL DATE ISSUED:05/30/2018
OWNER'S PHONE: PRONE NO:(415)763-4062
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class PLUMBING Lie.#857357
Contractor GAGNE BROTHERS ENTERPRISES INC Dale 0 413 012 0 1 9 X BLDG—ELECT X PLUMB
1 hereby affirm tlmt 1 em licensed ander 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:
PROPERTY LINE CLEANOUT
I hereby affirm under penalty of perjury one of the following two declarations:
r. 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
er£ormance 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;$3200.00
APPLICANT CF,RTIFICATION
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 369 17 051
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,the3pjAicant�r erstands and will comply with all non-point
source regul i6ns per the C perlino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Sign Dale 5-30-2018 Issued by:Kim Dunbar
Date:05/30/2018
OWNER-BUILDER DCCLARATION
I hereby affirm that I am exempt from the Contractor's License Law t'or ane of the RF.ROOFS•
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof's
r. 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(S-7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licmnsed Signature ofApplicmn:
contractors to construct the project(Sec.7044,Business&Professions Code), Date:5-30-2018
I hereby affirm under penalty of pcvjuy one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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
I I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requiraneats muder Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance o£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 wok for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store or handle hazardous
shall not employ to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
p y any person in any manner so as J r contaminants as defined by the Bay Area Air Quality Management District l
Worker's Compensation laws o£California.If,after making this certificate of will maintain compliance with the nrpertn NLrnicipnl Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety ode,Sections 505,25533,and 25534.
Labor Cade,1 must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized en
APPLICANT CERTIFICATION Date:5-30-2018
I certify that I have read this application and state that the above information is Ti ON I ENDING 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 ARCHrTEcT,s DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 5-30-2018 Professional