B-2018-1334 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1334
10184 POTTERS HATCH CMN CUPEXFI NO,CA 95014-2655(342 35 041) GAGNE BROTHERS
ENTERPRISES INC
NOVATO,CA 94949
OWNER'S NAME: DATE ISSUED:08/08/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C36 Lic.#857357
Contractor GAGNE BROTHERS ENTERPRISES INC Dale 04/30/2019 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 o£the Business&Professions Code and that my
license is in fail force and effect - JOB DESCRIPTION:
REPLACE 40 GAL WATER HEATER(SAME LOCATION)
I hereby affirm under penalty of perJury one of the following two declarations:
r. I have and will maintnin a certificate of consent to self-insure For Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
per£oomince 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 Lobar Code,for the performance of the work for which this
permit is issued Sq.Ft Floor Area: Valuation:$2700.00
APPLICANT CF.R'I-IFICATION
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 - 342 35 041
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,t pplica understands and will comply with all non-point
source regi tions_17
the upertino as rtpaTbo3e,section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Sign
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 reofing material being installed.Ifs roof is
r. I,as owner of the property,on my employees with wages as their sole installed without first obtaining en inspection,I agree to remove all new moteriols far
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sce.7044,Business&Professions Code)
2. I,us owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code), Date:8-8-2018
I hereby affirm under penalty of perjury one of the following three declinations: ALL ROOF COVERINGS TO BE CLASS"A"OR BET'T'ER
r. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided 1'or by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I hove and will maintain Worker's Compensation Insurance,as provided for by I have read the luvm•dnis 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 Cade,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I. I certify that in the performance of the work for which this permit is issued,I Henith&Safety Code,Section 2553200 should I store or handle haznrdors
shall notem to n n in manner so as to become subject to tlhe material.Additionally,should I use equipment or devices which emit hazardous
p y any person an y J air contaminants as defined by rea Air Quality Management District I
Worker's Compensation Imus of Culiforniu.If,after making this certificate of will maintain compliance Irtr lne Cupertiu uniclpal Code,Chupter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the Health& fety Code,Sections 2 505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked, Owner or authors
APPLICANT CERTIFICATION Date:8-8-2018
1 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 MunicipalARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 8 8-2018
Professional