10020023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10222 CARMEN RD COP TRACTOR:PATRICK KWOK PERMIT NO: 10020023
OWNER'S NAME:
CUPERTINO CA,CA 95014-2760 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
ADD 91 SQFT TO ENLARGE FAMILY ROOM IN REAR YARD&
ADD COVERED PORCH IN FRONT;REMODEL BEDROOM&
License Class Lic.# BAT 3,REPLACE WINDOWS,ONE SLIDING DOOR,NO
Contractor Date
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.
I hereby affirm under penalty of perjury one of the following two declarations: Sq.11 Floor Area: Valuation:$18000
1. 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. APN Number:35709011.00 Occupancy Type:
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.
PERMIT EXPIRES IF WORK IS NOT STARTED
APPLICANT CERTIFICATION WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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 and state laws relating 180 DAYS FROM LAST CALLED INSPECTION.
to building construction,and hereby authorize 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,judgmepts, Issu ed Date:v �j
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply with
all non-point source regulations per the Cupertino Municipal Code,Sectiori 9.18. RE-ROOFS:
Signature Date All r)ofs shall be inspected prior to any roofing material being installed.If a roof is
insta led without first obtaining an inspection,I agree to remove all new materials for
inspc ction.
a
OWNER-BUILDER DECLARATION Sign iture of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I,as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered for HAZARDOUS MATERIALS DISCLOSURE
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed c ntractors to I have read the hazardous materials requirements under Chapter 6.95 of the
construct the project(Sec.7044,Business&Professions Code). Cahibrnia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I hereby affirm under penalty of perjury one of the following three declarations: Safe y Code,Section 25532(a)should I store or handle hazardous material.
1. I have and will maintain a Certificate of Consent to self-insure for Worker's Ad&tionally,should I use equipment or devices which emit hazardous air
Compensation,as provided for by Section 3700 of the Labor Code,for the cont.rminants as defined by the Bay Area Air Quality Management District I will
mair tain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
performance of the work for which this permit is issued. Health& ty Code,Sections 25505,25533,and 25534.
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 Owner,
Date:
3. I certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's CONSTRUCTION LENDING AGENCY
Compensation laws of California. If,after making this certificate of exemption,I I herby affirm that there is a construction lending agency for the performance of work's
become subject to the Worker's Compensation provisions of the Labor Code,I for v hich this permit is issued(Sec.3097,Civ C.)
must forthwith comply with such provisions or this permit shall be deemed Lencler's Name
revoked.
Lencler's Address
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ARCHITECT'S DECLARATION
correct.I agree to comply with all city and county ordinances and state laws relating I unc erstand my plans shall be used as public records.
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lice rsed Professional
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
-,and expenses w %ch may accrue against said City in consequence of the
ing of this pe t Additionally,the applicant understands and will comply with
an non-point source r gulations per the Cupertino Municipal Code,S ction 9.18.
Signature Date
�' ��
CITY OF CUPERTINO BUILDING PERMIT -; .7E
BUILDING ADDRESS: 10222 CARMEN RD CONTRACTOR: PATRICK KWOK PERMIT NO: 10020023
OWNER'S NAME:
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic. #
Contractor
Date
1 hereby affirm that 1 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.
1 hereby affirm under penalty of perjury one of the following two declarations:
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.
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.
APPLICANT CERTIFICATION
1 certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize 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 may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Signature Date
OWNER -BUILDER DECLARATION
1 h reby affirm that I am exempt from the Contractor's License Law for one of
the NHowing two reasons:
1, as o er of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
declarations:
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.
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.
1 certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
1 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 and state laws relating
to building construction, and hereby authorize 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 expe7pt.
hich may accrue against said City in consequence of the
granting of this Additionally, the applicant understands and will comply
with all non- Cupertino Municipal Code, Section
9.18.
Signature Da��
CUPERTINO CA, CA 95014-2760 1 PHONE NO:
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
MECH F RESIDENTIAL F COMMERCIAL F
JOB DESCRIPTION: ADD 91 SQFT TO ENLARGE FAMILY ROOM IN REAR
YARD &
ADD COVERED PORCH IN FRONT; REMODEL BEDROOM &
BATH, REPLACE WINDOWS, ONE SLIDING DOOR, NO
8/11/10 - REV#1 - FOUNDATION, ADDING 2FT 81N BY 16FT TO REAR ADDITION
BY-8/1 I A 0 -REVSION ISS'D
Sq. Ft Floor Area: I Valuation: $18000
APN Number: 35709011.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DA S FROM L CALLED/INSPECTION.
Issued by: r V Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Additionally, should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Code, Sections 25505, 25533, and 25534.
Owner
Date:—le
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records.
Licensed Professional