B-2019-0826 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0826
21356 RUMFORD DR CUPERTINO,CA 95014-1334(326 41 014) Mol Marinus A And
Kobeh Monique Mol
Trustee
21356 Rumford Dr
Cupertino,CA 95014-
1334
OWNER'S NAME: DATE ISSUED:05/13/2019
OWNER'S PHONE: PHONE NO:408-306-0986
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class Lic.#
Contractor Mol Marinus AAnd Kobeh Monique Mol Trustee Date X BLDG X ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
KITCHEN REMODEL LIKE FOR LIKE-(165 SF); REMODEL
1 hereby affirm under penalty of perjury one of the following rico declarations: BATHROOM LIKE FOR LIKE-(40 SF);INSTALL 1/2" GAS LIKE TO
1. I have and will maintain a certificate of consent to self-insure for Worker's THE FIREPLACE INSERT-(34,000 BTU)AND INSTALL(1)OUTLET
Compensation,as provided for by Section 3700 of the Labor Code,for the FOR THE FIREPLACE; INSTALL(N)SUB-PANEL-(100 AMP)
performance of the work for which this permit is issued.
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. Sq.Ft Floor Area: Valuation: $49000.00
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 326 Number: Occupancy Type:
3
and state laws relating to building construction, and hereby authorize 26 41 014
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR.
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 05/19/2019 Issued by: Jasmine Archbold
Date: 05/13/2019
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any rooting material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials fo
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
contractors to construct the project(Sec.7044,Business&Professions Code). Date:05/19/2019
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perfonnance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
C3,) 1 certify that in the performance of the work for which this permit is.issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
Ashall not employ any person in any manner so as to become subject to the
material. Additionally,should I use equipment.or devices which emit hazardou,
/� air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 an(
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performanc(
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.