BLD-2023-1172_SignedPermit.pdf ITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS: 10146 CARMEN RD
ApN: 357 09 061
PERMIT NO: BLD-2023-1172
OWNER'S NAME: VAN KONINGSVELD GASPARD AND GONG FANG
OWNER'S PHONE: 6143906187
CONTRACTOR: OWNER -BUILDER
CONTRACTOR PHONE:
DATE ISSUED: Jun 20, 2024
TO CLEAR CODE CASE ENF-2021-0041 FOR UNPERMI (1 ED REMODEL AND ADDITION TO THE LOW
JOB DESCRIPTION: REMODEL 476 SF OF EXISTING BASEMENT; ADDITION LEGALIZE UNPERMITTED SPACE AT LOWER
LOWER -LEVEL REMODEL INCLUDES ADDING (2)BEDROOMS(711.43 SF);ADD (2) BATHROOMS -
REMODEL/ENLARGE (E) STAIRCASE;
DEMO (E) UNPERMITTED DECK AREAS;
(N) GAS TANKLESS WATER HEATER;
R LEVEL OF THE MAIN RESIDENCE -
LEVEL 454.27 SQ.FT; TOTAL LOWER LEVELAREA (BASEMENT HABITABLE AREA) (930.27 SQ.FT)
138.28 SF;
OWNER -BUILDER DECLARATION:
Law for one of the following two
with wages as their role compensation,
& Professions Code).
reasons:
will do the work, and the structure is not
to construct the project (Sec.7044, Business &
as provided for by Section 3700 of the
I hereby affirm that I am exempt from the Contractor's License
I, as owner of the property, or my employees
intended or offered for sale (Sec. 7044, Business
RII, as owner of the am exclusively contracting
with licensed contractors
declarations:
to self -insure for Worker's Compensation,
for which this permit is issued.
Insurance, as provided for by
is issued.
which this permit is issued, I shall
laws of California. If, after making
Labor Code, 1 must forthwith comply
property,
Profession Code).
I hereby affirm under penalty of perjury one of the following three
I have and will maintain a Certificate of Consent
Labor Code, for the performance of the work
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subj ect to
with such provisions or this permit shall be
I have and will maintain Worker's Compensation
performance of the work for which this permit
M I certify that in the performance of the work for
become subject to the Worker's Compensation
the Worker's Compensation provisions of the
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I
M I have read the hazardous materials requirements under Chapter
will maintain compliance with the Cupertino Municipal Code,
Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
handle hazardous material. Additionally, should I use equipment or devices which emit hazardous
Air Quality Management District I will maintain compliance with the Cupertino Municipal Code,
Sections 25505, 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
this project.
Firm Certification No:
QAn EPA Lead -Safe Certified Renovator will be responsible for
Certified Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued
Lender's Address:
I hereby affirm under penalty of perjury that there is a construction
(Section 8172, Civil Code).
0 Yes 0 No
Lender's Name:
APPLICATION CERTIFICATION
is correct. I agree to comply with all city and county ordinances and state
of this city to enter upon the above mentioned property for inspection
of Cupertino against liabilities, judgements, costs, and expenses which may accrue
the applicant understands and will comply with all non -point source
Date Jun 20, 2024
I certify that I have read this application and state that the above information
laws relating to building construction, and hereby authorize representatives
purposes. (We) agree to save indemnify and keep harmless the City
against said City in consequence of the granting of this permit. Additionally,
regulations per the Cupertino Municipal Code, Section 9.18.
Signature Ta499°n9
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 12 MONTHS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 12 MONTHS AFTER THE TIME THE WORK IS
COMMENCED.