B-2018-0928CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:
CONTRACTOR:
PERMIT NO: B-2018-0928
10815 NORTHVIEW SQ CUPERTINO, CA 95014-0541 (316 36 013)
GAGNE BROTHERS
ENTERPRISES INC
NOVATO, CA 94949
OWNER'S NAME: PUNNOLI GOPAKUMAR AND DEVADASAN INDULEKHA T
DATE ISSUED: 05/30/2018
OWNER'S PHONE:
PHONE NO: (
LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class C36 Lic. #857357
Contractor GAGNE BROTHERS ENTERPRISES INC Date 04/30/2019
X BLDG _ELECT X PLUMB
I hereby afflrm 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:
REPLACE WATER HEATER 40 GAL (SAME LOCATION)
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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.
have and will maintain Worker's Compensation Insurance, as provided for by
ection 3700 of the Labor Code, for the performance of the work for which this
V(--'P'ermit is issued.
Sq. Ft Floor Area:
Valuation: $2600.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
31636013
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 CuperWwraptrm fli ilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
cc
may a ruc said y in consequence of the granting of this permit.
Additionaft, th.e applicant u�derstands and will comply with all non -point
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
r'
Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
�— Date 05-30-2018
Issued by: Kim Dunbar
Cignatum
Date: 05/30/2018
B.
_B-1 , DECLARATION
0 R_B
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. 1, 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 (Sec.7044, Business & Professions Code)
2. 1, as owner of the property, am exclusively contracting with licensed
Signature ofApplicant:
contractors to construct the project (Sec.7044, Business & Professions Code).
Date: 05-30-2018
1 hereby affirm under penalty of perjury one of the following three declarations:
1. 1 have and will maintain a Certificate ofConsent to self -insure for Worker's
ALL ROOF COVERINGS TO BE CLASS "All OR BETTER
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. 1 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 of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. 1 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
Worker's Compensation laws of California. If, after making this certificate Of
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the �;�i �nicipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety �e, Sec�tions25 5, �and2553�4.
Labor Code, I must forthwith comply with such provisions or this permit shall
�25533,
be deemed revoked.
Owner or authorized acl
APPLICANT CERTIFICATION
Date: 05-30-2018
I certify that I have read this application and state that the above information is
CONSIRUCTION 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.
Signature Date 05-30-2018
Licensed
Professional
CONSTRUCTION PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT e BUILDING DIVISION
10300 TORRE AVENUE e CUPERTINO, CA 95014-3255
1�01 (408) 777-3228 * building@cupertino.or PEMIT #B -
C UPERTINO REV # DEF #
0 NEW CONSTRUCTION [_� ADDrriON R ALTERATIONF-1 T.I. F-1 MEP [__1 RE -ROOF F� SWIMWHNG POOL/SPA
In
PROJECT ADDRESS (:A -1b6 -PLV "b* I
APN # 3f � —_,2,�e - 0 1
OWNER NAME
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STREET ADDRESS
CITY, STATE, ZIP
Sam& e�ai�
I
CONTRACTOR NAME D OWNER -BUILDER
COMPANY NAME
LICENSE NUMBER LICENSE
TYPE
STREET ADDRESS
�)�_ Dc � n�_�
CITY� STATE, ZIP
U'Np,_� Ctq Ct L4 61 L-1
E-M,A1_L
PHONE
BUS.
ARC1-HTECT [I OWNER 0 OWNER AGENT )OPCONTRACTOR AGENT E:l ENGINEER [I DEVELOPER El TENANT
CONTACT NAME E-MAIL
STREET ADDRESS CITY, STATE, ZIP PHONE
<;&Me 0-S clvr,
DESCRIPTON
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q�SINGLE-FAMILY/DUPLEX EIMULTI-FAMILY []INDUSTRIAL []COMMERCIAL
USE
TYPE
OCC
SQ.FT.
VALUATION
EXISTING USE
I EXISTING SF
NEW FLOOR SF
RC
I PO HSF
DECK SF
I DEMO SF I
STORIES #
� TOTAL NET SF
REMODEL
REMODEL KITCHEN
REMODEL OTHR
GARAGE [] ATTACHED
BATHROOM SF
SF
SF
SF El DETACHED
EXISING [3 YES
EICHLER El YES
I
SECOND STORY ADDITION E] YES
FIRE SPRINKLERS E:l NO
[I NO
El NO
DWELLING SECOND DWELLING EIYES [:]ATTACHED[:] DETACHED
OTHER
UNITS # UNIT ADDITON: 0 NO SF I
I
POOLS1 [] FIBERGLASS 0 VINYL -LINED [:] GUNITE E] PREFABRICATED
POOL - SF SPA - SF I SPA ATTACHED El YES [I NO I TOTAL - SF
REC
TOT41, VALUATION:
Commercial or Multi-Famffy Buildinv, with Public Swimming Pools reguires Department offirvironmental Heath ap�roval
' & _-,
1,1ce 6 C-)
RE-ROOFIEXISTTNG
—
ROOF TYPE: E]BUILT-UPROOFF] ASPHALT SHINGLES D WOOD SHAKESE]
� -
WOOD SHINGLESE] TILE OTHER (SPECIFY)
REMOVE /REPLACE rl NO
IF NO
PLYWOODE] %" [:] 3/8" PLYWOOD
TYPE:
PITCH:
ROOF CLASS
E]YES
I # OF LAYERS
THICKNESS [-] 5/8- OTHER I
0OSB E] CDX OTHER
:12
A
PROPOSED ROOF TYPE: EIBUILT-UP ROOF EIASPHALT SHINGLES El WOOD SHAKES DWOOD SHINGLES 0 OTHER
*Provide a signed copy of the Cupertino's Tear -Off Policy SF_ #ofSQUARES
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 local ordinances and state laws relating to building construction. I authorize representatives of Cupertino to
enter the above -identified prOp�erty fo 1 1 au thorize all information contained on this application form
to be made available for public �rd.�
urposes. �Iackn�owledge �and
(!��]
Signature of Applicant/Agent. Date: L
— — -
SUPPLEMENTAL INFORMATION-giTU—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 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.doe revised 08101117