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14120007CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 21356 RUMFORD DR CONTRACTOR: MARC MOL PERMIT NO: 14120007 OWNER'S NAME: MARC MOL 21356 RUMFORD DR DATE ISSUED: 12/01/2014 OWNER'S PHONE: 4082539935 CUPERTINO CA, 95014-1334 PHONE NO: JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL E] ❑ LICENSED CONTRACTOR'S DECLARATION REMODEL & RECONFIGURE (E) MASTER & HALL BATHS License Class Lic. # (108 S.F.) 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. Sq. Ft Floor Area: Valuation: $11000 I have and will maintain Worker's Compensation Insurance, as provided for by APN Number: 32641014 00 Occupancy Type: 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 PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITBIN 180 DAYS O IT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter 180 DAYS LAST LED INSPECTION. 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 Iss Date: l granting of this permit. Additionally, the applicant understands and will comply Y' with all non-point source regulations per the Cupertino Municipal Code, Section 9 18. RE-ROOFS: Signature Date 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-BUILDER DECLARATION Signature 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 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 sale (Sec.7044, Business & Professions Code) , as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). have read the hazardous materials requirements under Chapter 6.95 of the 1.1 California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three al ode, Chapter 9.12 and the maintain compliance with the Cupertik,a declarations: Health & Safety Code, Section 25532(e or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally, should I use eqdevices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bauality Management District I of the work for which this permit is issued. will maintain compliance with the Cuici al Code, Chapter 9.12 and performance I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25an 25534.Section 3700 of the Labor Code, for the performance of the work for which this Owner or authorized agent:Date: 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 I I hereby affirm that there is a construction lending agency for the performance of become subject to the Worker's Compensation provisions of the Labor Code, must work's for which this permit is issued (Sec. 3097, Civ C ) forthwith comply with such provisions or this permit shall be deemed revoked. 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 ARCHITECT'S DECLARATION indemnify and keep harmless e City of Cupertino against liabilities, judgments, costs, and expenses which accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Add Tonally, the applicant understands and will comply with all non-point source r ula 'ons per the Cupertino Municipal Code, Section Licensed Professional 918. Signature Date/ILI CUPERTINO CONSTRUCTION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 (408) 777-3228 • FAX (408) 777-3333 - building(&-cupertino.org ❑ NEW CONSTRUCTION ❑ ADDITION R@ ALTERATION / TI ❑ REVISION / DEFERRED ORIGINAL PERMIT # PROJECT ADDRESS 6 Ri., 0 L APN # -d / /1 OWNER NAMEM. PHONE`` 8) x S `S L V 1AM I � � O (2 3 � (7 . 1M 0 %N ! , I (\ STREET ADDRESS / 1 5 S 6 /�. Y -pt CrrY STIATE, ZIP C- ©11 FAX 'i R � 0 Yf V 1^ 1 O CONTACT NAME �� /^� P + P O 9i -3 - 35 E-�?�u. �pc�r� Sl I Y IGIV,1 (9 o� Y�1�YdC� yVloz . STREET ADDRESS / .9113 5 �O ccw. v a� �� C STATE, I` cA -ew I -t-c:>/�' s o rr FAX -_ ❑ OWNER 91 OWNER-BURDER ❑ OWNERAGENT ❑ CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ EN. ❑ DEVELOPER ❑ TENANT CONTRACTOR NAME i +�' rj D 1 W LICENSE NUMBER -T LICENSE TYPE BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS. LIC # COMPANY NAME E-MAIL FAX STREET ADDRESS CITY, STATE, ZIP PHONE DESCRIPTION OF WOIjK� 5 �_ ` ,/I _ _O Al �.-, ® / /Z� 7i'?�.() / -;(L L� `�, L n TM 3 S ( C) iii P'�` hi -K rp,9O PROPOSED USE CONSTRTYPE �1 /D"EMO #STORIES USE TYPE OCC. SQ.FT. VALUATION (S) EXISTG NEW FLOOR TOTAL AREA AREA AREA NET AREA BATHROOMn REMODEL AREA ,F KITCHEN REEM1,54fODEL AREA OTHER REMODEL AREA o I PORCH AREA DECK A TOTAL DECK/PORCH AREA GARAGE AREA DETACH []ATTACH I # DWELLING UNITS: ISASECOND UNrT ❑YES SECONDSTORY []YES BEING ADDED? ONO ADDITION? ❑NO PRE -APPLICATION ❑ YES IF YES, PROVIDE COPY OF IS THE BLDG AN ❑ YES TOTAL VALUATION: PLANNING APPL # ❑ NO PLANNING APPROVAL LETTER EICHLER HOME? ❑ NO O Q By my signature below, I certify to each of the folio : I am the property owner or authorized act on the property owner's behalf. I have read this application and the information I have provided is rrect. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and state laws relating to building I authorize representatives of Cupertino to enter the above -identified property for inspection purposes. Signature of Applicant/Agent: f Date: SUPPLEMENTAL INFO TION REQUIRED PLAN CHECK TYPE ROUTING SLIP �' OVER-TH&COUlvTER ❑ BUILDING PLAN REVIEW _ New SFD or Multifamily dwellings: Apply for demolition permit for existing building(s). Demolition permit is required prior to issuance of building permit for new building. ❑ EXPRESS ❑ PLANNING PLAN REVIEW _ Commercial Bldgs: Provide a completed Hazardous Materials Disclosure ❑ STANDARD ❑ PUBLIC WORKS form if any Hazardous Materials are being used as part of this project. ❑ ❑ 'DEPT LARGE FW _ Copy of Planning Approval Letter or Meeting with Planning prior to ❑ ❑ submittal of Building Permit application. MAJOR SANITARY SEWER DISTRICT ❑ ENVIRONMENTAL HEALTH BldgApp 201 Ldoc revised 06/21/11 "F -1- 9/6-T CITY OF CUPERTINO FEF E4TIMATOR — BUILDING DIVISION im,ADDRESS: 21356 RUMFORD DR DATE: 12/01/2014 REVIEWED BY: melissa APN: 326 41 014 BP#: *VALUATION: Isi1,000 xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair PRIMARY USE: SFD or Duplex 0.0 PENTAMATION PERMIT TYPE: 1 R3SFDRE WORK REMODEL E MASTER & HALL BATHS 108 S.F. SCOPE 10",-/r'£ :l'i"£'h fYtj:''3. I3hwib. 1'.wi £:'61ecA 01her Plumb 7nv?. lllwi b7 lt1gi. Fee ;lec. l ,E , 0/6'e7` / "Cc '4?yp, Ir'<zc. Ins'. NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, tire, Sanitary Fewer utstrict, Scnooi -fees are based on the relimina information available and are onlyan estimate. Contact the Detor addn'l info, District, eta). These_f FEE ITEMS aW Resolution 11-053 Eff. 7/1/131 FEE QTY/FEE MISC ITEMS Plan Check Fee: $0.00 108 s.f. Remodel, Bath (<=300 sf) $645.00 11?EMRESBAT Suppl. PC Fee: (j) Reg. ® OT 0.0 hrs $0.00 PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Feer Reg. 0 OT k.0 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 Consti,uctill)n LV: 0 Work Without Permit? 0 Yes E) No $0.00 Advanced Planning Fee: $0.00 Select a Non -Residential G Building or Structure Strong Motion Fee: IBSEISMICR $1.43 Select an Administrative Item Bld.a Stds Commission Fee: 1BCBSC $1.00 $2.43 $645.00$647.43 FEE:, $647.43 y, Revised: 10/0112014 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(ftupertino.org 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 ADDRE S APN -sxBPIF U 07 NER NAME OWNER 7DR S CAV'1 0 1 6-6 U r tr I kcy `vl DESCRIPTION OF VVORK: ®® W, v G(/VL D �i t'i1Cc5 eco t 0 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.) 04 4 1. 1 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. I am willfully acting as an Owner -Builder and am aware of the limits of my insurance coverage for injuries to workers on my property. IX 04 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 _3. I understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I 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. /1^ 4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. IA�L_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. Mfv� 6. 1 understand if 1 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. A1�17. I 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 4. 1 understand as an Owner -Builder if I sell the propelrty 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. OwnerBuilderForm 2010.doc revised 04114110 9. 1 understand 1 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.csib.ca.gov for more information about licensed contractors. / Wl 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. i LA 11. 1 agree that, as the party legally and financially reponsible for this proposed construction activity, I will abide by all applicable laws and requirements that govern Owner -Builders as well as employers. IA 12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the information I 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.) A Lender Name: /u lk Lender Address: Before a building permit can be issued, this forltmust be completed and signed by the property owner and returned to the agency responsible for issuing he permit. Note: A copy of the property owner's driver's license, form notarization, or other verification acceptabl.71:1 o the city mi 4y be required to be presented when the permit is issued to venfv the property owner's signature. , , � ] / Property Owner's Signature: ,f%` __ Date:10<, / 1-1 i ---------------------------------------------------------------------- ---------------------------------------------------------------------- (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 authorize the following person(s) to act as my agent(s) to 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: I understand is my personal responsibility, I hereby for, sign, and file the documents necessary to obtain an 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 driver's 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 owner's signature. Property Owner's Signature: Date: OwnerBuilderForm 2010.doc revised 04/14/10 Po- ► e, J 1 I la m,, vest s WIC, o,3 CA g L P6 CObas A P?1-y U L- 0 O �L X W Upstairs hallway CUPERTI Building Depai .0 s 25la1 =D FOR CODE COMMP iewed By: `40rY- Upstairs hallway bathr I VLO V45 6 0 � — existing 0 ICE Copyo I011-01UT'A DEC 01 2014 BY Furnace flue and ducts Closet Master ba hr �xi tli CEVELOPMENT D ARTMEN BUILDING DIVISION - PERTINO APPR0 D This set of plans and specific ons MUST be kept at tI ;cb site during construction It is unlawful to make all changes or alteration on same, or to devial therefrom, without appro al from the Building Offi6 The Stamping of this plan nd specifications SHALL N( be held to permit or to be all iUlu vikilakilk Exterior PERMIT # UPSTAIRS BATHROOMS — FLOOR PLAN - EXISTING to CIO y '-F (D rr rD a - 0 O DS = Dimmer switch UPSTAIRS BATHROOMS — ELECTRICAL PLAN - EXISTING Shower drain with trap (2") UPSTAIRS BATHROOMS — PLUMBING PLAN - EXISTING ick (2") Venack (1.5 ne Upstairs hallway Rjjav'"ERT/nI g Oo Exterior UPSTAIRS BATHROOMS — FLOOR PLAN - PROPOSED I u Bathroom fan / light combo Bath fan / coml DS = Dimmer switch S = Switch GFCI Upstairs hallway bath Cup Ftri�, _x ," 'k CW 6y -proposed Master bathroom - proposed UPSTAIRS BATHROOMS — ELECTRICAL PLAN - PROPOSED Rjj)o 'AY TiAIA% UPSTAIRS BATHROOMS - PLUMBING PLAN - PROPOSE® Building Department, City of Cupertino Att. Patricia Garcia 10300 Torre Avenue Cupertino, CA95014-3255 Date: September 8, 2015 Subject: Building permit extension request Permit No: 14120007 Dear Patricia, In response to your Building Permit Expiration Notice dated August 20, 2015, 1 would like to request an extension of Permit No 14120007 (Remodel & Reconfigure (E) Master and Hall Baths (108 S.F.) — expires 9/9/2015). As the homeowner, I have chosen to perform most of the remodeling tasks myself. Due to unforeseen personal and professional circumstances I did not have as much spare time to dedicate to the bath remodel as initially predicted, causing the next inspection to be pushed out by another couple of weeks. Thank you very much for your consideration. f —oil Best regards, � f Marc Mol 21356 Rumford Dr. Cupertino, CA 95014 (408) 253-9935 fiaQ J'z"l G m�