10020023 REV2 ;W
CITY OF CUPERTINO BUILDING PERMIT - // ---1 �
-DING ADDRESS: 10222 CARMEN RD ;- � �"
OWNER'S NAME: PATRICK KWOK CONTRACTOR:PATRICK KWOK PERMIT NO: 10020023
10222 CARMEN RD DATE ISSUED:06/21/2010
I OWNER'S PHONE: 4082574934 C'UPERTINO CA,CA 95014-2760 PHONE NO:
LICENSED CONTRACTOR'S DECLARATION
E UILDING PERMIT INFO: BLDG ELECT r PLUMB r
License Class Lic.#
Contractor Date MECH RESIDENTIAL r COMMERCIAL
1 hereby affirm that I am licensed under the provisions of Chapter 9 J':)B DESCRIPTION:ADD 91 SQFT TO ENLARGE FAMILY ROOM IN REAR
(commencing with Section 7000)of Division 3 of the Business&Professions Y aRD&
Code and that my license is in full force and effect. A 3D COVERED PORCH IN FRONT;REMODEL BEDROOM&
1 hereby affirm under penalty of perjury one of the following two declaratB,�TH,REPLACE WINDOWS,ONE SLIDING DOOR,NO
ions:
1 have and will maintain a certificate of consent to self-insure for Worker's 8/ 1/10-REV#I-FOUNDATION,ADDING 2FT 81N BY 16FT TO REAR ADDITION
B"-8/1 I/10-REVSION ISS'D
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.
Sq.Ft Floor Area: Valuation:$18000
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 AF N Number:35709011.04 ane Occu
Occupancy Type:
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 against
against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 180 DA S FROM L CALLED INSPECTION.
Signature Date_ Issued by: Date:
OWNER-BUILDER DECLARATION
reby affirm that I am exempt from the Contractor's License Law for one of
the flowing two reasons: RE-ROOFS:
1,as o er of the roe All,oofs shall be inspected prior to any roofing material being installed.If a roof is
property,rty,or my employees.with wages as their sole compensation, Inst,lled without first obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, insp:ction.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant:
construct the project(Sec.7044,Business&Professions Code). Date:
I hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
performance of the work for which this permit is issued. I hai a read the hazardous,materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this coml fiance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
permit is issued. Safet y Code,Section 25532(a)should I store or handle hazardous material.
1 certify that in the performance of the work for which this permit is issued,1 shall Addi Tonally,should I use equipment or devices which emit hazardous air
not employ an contaminants as defined by the Bay Area Air Quality Management District 1 will
P Y y person in any manner so as to become subject to the Worker's main ain compliance with,'the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health%70riz
Code,Sections 25505,25533,and 25534.
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. Own(r��o' d ent:
Date:
APPLICANT CERTIFICATION ( v
I 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 relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expens hick may accrue against said City in consequence of the Lender's Address
granting of this p t.Additionally,the applicant understands and will comply
all non-po' t urce re ns per the Cupertino Municipal Code,Section
/ ARCHITECT'S DECLARATION
Signature ��./ Darr r� r. 1 under stand my plans shall be used as public records.
Licens:d Professional