12020021 i
CITY-01F CUPERTINO BUILDING PE'RIVIIT
BUICDING�ADDRESS:' 841:ROSE°BLOSSOM DR CONTRACTOR:GREG&3CHERYL PERMIT NO: 12020021
BRESHEARS
;OWNER'S NAME::,GREG&CHERYL"BRESHEARS 841 ROSE`BLOSSOIvI DR. DATE ISSUED:06/1.2/2012
OWNER'S PHONE:4086/33085 CUPERTINO;CA 9501'4 PHONE NO:
,❑ LICENSED,CONTRACTOR,'S DECL"•ARATION_ JOB DESGRIP,_ION RESIDENTIAL 1:1 COMMERCIALS
Llcense,Class tiic'..# ADDITION OF 721 SQ FT`'TO FRONT OF1SFDWL,.
REMODEL
;Contractor _ Date BATH 60'SQ FT'/KITCHEN 1'00:SQ FT/OT14ER200,SQ
1 herebyaffrm that I atnaicensed uodertthe p[ovisions,of'Chapter;9 FT, UPGRADE MAIN,ELECTRICAL,.PANE'L T.O 20.0'.AiiR
�'(cominencing,with"Section`7000)ofpivision,3=of the,Busine,ss&Piofessions
Code and'thai my.licens,is in full force and effect,
I=herebyaffirro under penalty oGpe�JuryOne ofthe,followingawo declarations:
I have and;will,rnaintain®a"certificate of consent.toself-insure�for^Worker's
Compensation;asfprovided'for by,;Section 3700 of the LaborCode,for the
performance ofthe°work'forwhicithis,,perrnit',is=issued. Sq.Ft FI'oor.Area: Valuation:$180000
1,have and,will,maintain Worker's Compensation Insurance;,as provided for by
Seciion�3700 ofa_he_Labor'Code;forthe'perfornrance:of the;woik for which this
APN Number:35903044:06 Occupancy Type:
permitis.issued.
APPLICANT'CERTIFICATfON
I`ceitifyAtliat l have ieail this application and state.that'the above infoima,_ is, PERMIT _PIRES IF WORK IS NOSTARTED
correct..I agree to comply with;all city and county:ordinances"andjstate laws relating _ EXT'-
to:building'construction,and herebyauthor_ize representatives ofithisxity to enter WITHIN 1 0' AYS OF PERMIT`ISSIIANCE OR
upon the;above'mentioned,prop-erty�for inspection,purposes. (We)agree tosave 180 DA. M LAST CALLED INSPECTION.,
ndemnify°and keep harmless the City ofCupeRino agamsChabilities,judgments,
costs and,expenses which may &,
accragamst said City in.consequence,ofthe 11,7 J�li
granting ofthis permit. Additionally,the applicantundersiands;and,will comply Issued by: Date' .
with-all,non pointsource regulations°per the Cupertino Municipal Code,Section
9.18.-
RE-ROOM
Signature- Date All roofs;;shaltbeinspected;pnor'to any,roofing material being installed.If a roof is
`installed�without fr`st'obtaining,an inspection,,fagree`to remove,all.ne,w,materials for
inspection.
OWNER-BUI CDER.DECLARATION
Signature of.Applicaric Date:
I herebyaffirm thatl am:exempt`from the Contractor's License'Law, for one of
the following two reasons: ALL ROOF COVERINGSTO BE CLASS"•A OR.BETTER
I,as 6wneroftheTproperty,ormy.employees°with wages as the it,solewcompensation,
will do,the work,and the structure is=noVintended:or,offered for sal ea(Sec.7044,
Business,&Professions Code)
I,as`owne_r ofr,the property;an exclusively contracting with,licen'sed contractors to HAZ'ARDOUSMATERIALS DISCLOSURE
construct the•project(Sec:7,044„Business,&Professions Code): I"have read tlieahazar"dous+materials requirements under Chapter 6195 of.4he
California Health,&'Safety Code„Sections 355051!25533,and'25534..I will
L'hereby.affirm under penalty-of perjury one,ofthe.followingithree' maintain compliance theCupertino Municipal_Code,Chapter1.12 aod,'the-
declarations: Health&°Safety Code;Section 25532(a)should_I store or handle hazardous
.1 have and,,will`.maintain&Certificate of Consentto,self-insure for Worker's material: Add iiionally,ishould'I use equipment or devices,which,`einit hazardous
Compensation,astptov..ided.for by.Section,3700;ofdie Labor Code;'for the air•contaminants,as defined by the.Bay Area Air":Quality.Management Oistrict'I
performance of the work_forwhicfi this permit+is issued. will maintaih:compliance with'theCupertino 111u "cipal Eode_,iCFiapter 9.12 and
' theMcaltfi&LSafe Cod- e_
l have add "maintain.W orker,s;Compensation lnsurance,,as provided for by ty " e,S_ctions _ ;and 25534:
S;ectiom.3700 ofithe.Labor''Code,for tiie?performance of the work for,which,this � � �
Permit is issued. Owner or,authorized agent:; .Date lO”12
I certify=thatin theiperforiii to of'the work for which'this`perm-it.isissued;l'shall
not employ any person m+any_manner so as'to`become=subject to the Worket's'
ComperisationJawsofCalifornia. if,affermaking:this•certifcate:of'exemption,,�l CONSTRUCTION LENDING-�AGE�NCY
Become subject to the--Worker',s''Compensatiomprovisidris-of the,Libor"Code,•1'mus,t •t hereby affirm that there,is a construcfionaending,agency for"the performance of
'forthwith.comply-With such'provisions or this'permifshall bvdeemed.revoked., .work's�for whwh'thislPerm&is=issued(Sec.3097,Civ-C.)
;Lender's,Name
AP.P.LICANT CERTIFICATION Lender's:Address
1 certifythai thaveiread,thisiappljcation,and.state that.the,above�inforination is
correct. I.agree1o;comply.with all cityand county-ordinances and stateaaws relating
to building:construction;,and hereby..auttiorize representatives.ofthfs citytosenter
upon the above mentioned'pr operty'for.inspecuonpurposes.(We);agree�to;save
°19deminif7,and keeP�iarmle"sslthe"Ci of Cupertino against liabilitiesJud meri AReHITECT'S DECLARATION
--
costs,and expenses wh'rch.may'accrueeagamstsaid City,m consequence of.the J understand';my,plans;shall,be:used as„public_"records.
granting,of this permit.Additionally,the applicant undeistandsFand�w--I comply
with all non-pointisource.regulations pertfie,Cupertino MIunicipal.Code,Section Licensed'Professional
9.J'8. n
Signature. Date.': ✓�
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— CITY; ' C t `TIN
FES. ESTI AT a. UXING I' N
DORESS:=841:'Rose �B'�ssom ®r, I)vTE 02L46t2Q i 2" REJTEWE-D Bv, jsg'
-
APNc 359-03-044 gP#: V'aLOATiON: $180 000
/ O�Z 06
PEPAiT T1'PE: Building Permit' f'L'N'C�ECK I1'P A'dditi®n
_ r
MilYIArRY P ._ 2nd Uuft? Yes
• No k' NT 11L14TIC1N
SFS or Du lex 1 R3sPbA®D
[JSE:, Tc
? Yes
.. PERItiii TY1E: _
WORK Additibn and remodel. ae,&. ara•e,aM &,ch .add`721,s 'ft rerriodd 360 s 'ft
SCOPE -
OC'CL�PANC_Y'TYPE: PC FPES TC,F`EE+ I®' �>�P FEES. BP FEE ID
`
R-3(Custom) II`B;III B IUV'B. 721 $2;420:'00 IR3PLN('K 1 51'9.00 IR�IN�`F'
( } $
TOT SLS: 72.1 $2;420 00 $1 51.9'00
<^tom'+� � ,� - ', {S'(� 6 � � kr;. - ,w t�< •, t
,.
N(3TE:,T/gisesti»u[te.does`nbtprnclrade,��es,di[etr�:otherl)eprirtrrts?tttc.(ise.Pdunning;Public.6i'or`ks, Fire,Sar�tarv-�etv�rD_tsirict Sc°trioC:
_:I3astrrrt;_etc' _.`7![ese,' es[etc'iiased on tt a�reliia liar iiz cyrnatttzon itviulrible and,arewnly'dn,evftmdte. Gonta'et the-D jt oi°addri'l in o:.
,c,s..,Stec ff l 1-:ea a FEE' T.Y. YFEE [1[ SC: [T 1lIS
FEE ITEMS r '> er ,s t ; (�;.
Man Check Fee: $2,420'.00 6Q s;f Remodel.Bath(<=300,sf1
Suppl.PC-Ree: Q Reg. 'Q EST O.:Q hrs $O:QO $;5wooPE-NIRESBAT�
PMETIan Check: $O.C10 100 s.f; Reizi®del,Kitdhenv(<=3'Ou sf j
P-eimit Fez:, 1REAMESKI
'SttppL,[nsp Fee-e Reg, Q OT 0_® firs $0`',®0 2ClQT s.f. .I exn®ciei,®ther,
MfE fii t�Fee, $Q.0®. $302'.00] i'RE`MhE,sQTH`
P_ME'Permit Fee: $0:'00:
In 7
Wcirl:`-itfibul P.erttiEt? Y`es- • -Nig
Adc;_arssbd Pl �_:3i1� TLS:; PLb`U4C�RNCR $93.,73 Select-a Noti-Resi�tzntial
- -
`Buildirig�br Skitctiire•
_. .... A
Sttk)ze<= [vtodo IBSEIS_AW17 $18;00 Select an Adnun[strative Item
_ .... .
I3Wtcds,i bEi-ims si'era:hte: I ?GdSG $8 C1'0
mss . TC)TA�Fyp
5,626.73
W.11INt.; .. � � r.� StI B 3 v4L $4;,05 .73 1,568 0'0 „
._
Revised: 14012012