13050017CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21356 RUMFORD DR
OWNER'S NAME: MARC MOL
OWNER'S PHONE: 4082539935
❑ LICENSED CONTRACTOR'S DECLARATION
License Class Lic..# ,
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:
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.
APPLICANT CERTIFICATION
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
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
CONTRACTOR: MARC MOL PERMIT NO: 13050017
21356 RUMFORD DR DATE ISSUED: 05/02/2013
CUPERTINO CA, 95014 -1334 PHONE NO:
JOB DESCRIPTION: RESIDENTIAL L1 COMMERCIAL
REMOVE AND REPLACE 2 SLIDING GLASS PATIO DOORS
Sq. Ft Floor Area: Valuation: $5076
APN Number: 32641014.00 Occupancy Type:
PE RMI XPIRES IF WORK IS NOT STARTED
WIT 180 DAYS OF PERMIT ISSUANCE OR
180 D S OM LAST CALLED INSPECTION.
Issued by: Dat .
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.
OWNER= BUILDEKDECLARATION
Signature of Applicant: Date:
I hereby affirm that l am exempt from the Contractor's License Law for one of
the following two reasons: i.
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I, as owner of the, property, or my employees with wages as their sole compensation,
will do the work, and the structure is riot intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self - insure for Worker's
material. Additionally, should I use a Ment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Ba Area Air Quality Management District I
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
will maintain compliance with the Cq6ertino Municipal Code, Chapter 9.12 and
the Health & Safety Code, Sections 05, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date* 1u r r,
permit is issued.
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
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
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
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 harmle s the City of Cupertino against liabilities, judgments,
costs, and expenses which ay accrue against said City in consequence of the
granting of this permit. A ditionally, the applicant understands and will comply
with all non -point sourc .regulations,per the Cupertino Municipal Code, Section
9.18.
Date
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
1PUI i li`CTTM A Tl1R _ RTTTT .11INC: DIVIRION
ADDRESS: 21356; RUMFORD DR
DATE: 05/02/2013
REVIEWED BY: MENDEZ
APN:
BP #:
*VALUATION:
1$5,077
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY
SFD or Duplex
PENTAMATION 1GENRES
PERMIT TYPE: i
USE:
WORK
REMOVE AND REPLACE 2- SLIDING GLASS PATIO DOORS
SCOPE
ecTr. Ilan Check PluutL Plan Check Elec. Plan Cheek
Wech. Permit Plumb. Permit Fee.: Elec. Permit Fee:
her rllech. In Other" Plumb Insp. Other flee. Insp.
ech. Insp, Fee:, Plumb. htsp. Fee: Elee. Insr. fire:
VOTE. Thic estimate does not include fees due to other Departments (Le, Planning, Public Works, Fire, Sanitary Sewer District, School
District, etc). These fees are based on the preftinin a
FEE ITEMS (Fee Resolution 11 -053 E 7if 11112)
Plan Check Fee:
Suppl. PC Fee: (F) Reg. 0, OT 0.0 I hrs
PME Plan Check:
Permit Fee:
Suppl. Insp. Fee: Reg. Q OT 0,0 hrs
PME Unit Fee:
PME Permit Fee:
C( ::.7 -ax.
Administrative .Fee:
Work Without Permit? 0 Yes (E) No
Advanced Planning Fee:.,
Trav>,l Docuanentcation Fees:
Strong Motion Fee: IBSEISMICR
Bldg Stds Commission Fee: 1BCBSC
madon available and are only an estimate. Contact the wept for aaan'c info.
FEE QTY/FEE MISC ITEMS
$0.00 I 2 J # Window / Sliding Glass Door
$0.00 $400.00 IWINREP Replacement
$0.00
$0.00
$0.00
$0.00
$0.00
CUPERTINO
OWNER- BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION
10300 TORRE AVENUE - CUPERTINO, CA 95014 -3255
(408) 777 -3228 - FAX (408) 777 -3333 - building(cDcupertino.or4
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS k Z .S S M«O R p IQ APN B
OWNER NAME OWNER ADDRESS
DESCRIPTION OF.WORK:. ta CA WO on, 1, c6p v
We. are providing you with an Owner - Builder Acknowledgment and Information Verification Form to make you aware' of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner - Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.)
A!-1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner.– -
Builder" building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner - Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. 1 am willfully acting as an Owner - Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and. are not hiring a licensed Contractor to assume this responsibility.
M*'4 3. 1 understand as an "Owner- Builder" I am the responsible party of record on the permit. I understand that. l may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
t,fift-4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
ihd!�_5. I: understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer" under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner - Builder who builds single - family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
t�414 8. 1 understand as an Owner - Builder if I sell the property for which this permit is issued, I may be held liable for
any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction
defects in the workmanship or materials.
OwnerBuildeYForm 2010.doc revised 04/14/10
y
W 9. 1 understand I may obtain more information regarding my obligations as an "employer" from the Internal
Revenue Service, the United States Small Business Administration, the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB) at 1- 800 - 321 -CSLB (2752) or www.cs[b.ca.gov for more information about licensed
contractors.
10. 1 am aware of and consent to an Owner - Builder building permit applied for in my name, and understand that I
am the party legally and financially responsible for proposed construction activity at the site address listed above.
11. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all applicable laws and requirements that govern Owner - Builders as well as employers.
i 12, I .agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information 1 have provided on:this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner - Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS: please complete the following construction lending agency information.)
I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.).
Lender Name: Lender Address:
Before a building permit can be issued, this
returned to the agency responsible for issui
form notarization, or other verification acceptab
to veri fy the property owner's si nature,
Property Owner's Signature:
must be completed and signed by the property owner and
the permit. Note: A copy of the property owner's driver's license,
o the city may be required to be presented when the permit is issued
Date:
------------------------
- - - -
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner - Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property.Owner, the execution of which I understand is my personal responsibility, I hereby_
authorize the following person(s)16 act as my agent(s) to apply for, sign, and file the documents necessary to obtain an
Owner - Builder Permit for my project.
Scope of Construction Project (or Description of Work):
Project Location or Address:
Name of Authorized Agent:
Address of Authorized Agent:
Tel No
I declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note: A copy of the property owner's drivers license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owners
signature.
Property Owner's Signature:
Date:
OwneYBuilderForm 2010.doc revised 04114110
Marc Mol [Project: 41673]
21356 Rumford Dr
Cupertino, CA 95014
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