01010020 CITY OF CUPERTINO
43UILDING DIVISION PERMIT CONTRACTOR INFORMATION:.'1
' BUILDING ADDRESS'. r PERMIT NO. -
10605 S BLANEY AV01010020 '
OWNER'S NAME: +" S APPLICATION SUB DA'fF. '
PfioAwry
STEINBERG. ROBERT J AND TERL 01 04/LO0DNTRDLNo.
GOO ARCHITECTIENGINEER: - - - BUILDING PERMIT INFO ^
- ` - BI.DG ELECT PLUMB MECH
a z mI�
as
Z I ICI NSI DCONIRACIOk S DECI 1RAl'ION - f Job Description
D 1 thereby 0 Int 1 licensed d p f Chapter 91co nom g - p .
,« 'tlS I 91X11) fU n3aflh.Bu dP '..inns Code and it,l
3 Lio "ecla" IIrel Lie 4 REPLACE.,50--GALLON GAS WATER HEATER.
h Date Contractor
ARCDITEC'IS DECLARATION .
C I midearktand it,al . hell be used public,`rodaNn' • - .
T
�p p LiccnscA Professional «
OWNER-BUILDER DF.Ce Corutmcdar' ' t +
1 hereby nllinn Iliat 1 am exempt fmm the C.nlmetur's License Lawlor the ..
C < following nav,n.(Smlinn](131$;ILlsinexs and Pidesslons Cade:Any city oreounly
4'2❑ which requires aperant1 t t II eJI f:h P ' y structure ' « -
, mpr, I. 9 m plf tf hp n II 6 Ili mmen .
that he i,humn,vidp : ,offic provisions orthConnectors Luccute,Law(Cil ptern Sq. Ft. FloorArea - - Valuation .
-(en gee IIS I ]100) flit ' l Itl R IP r .......' Ede) ,.
or
hill he is exem,t libleadmar ad(he ha,i,for it II g d torunU R.A y holudion ' $ «�
arsi 70315 by any pvi lfrap h bpeh,the r'l uri'd'.yhy
54
ornot nethan live hundred dollars'1110). APNNumber,- _ Occupancy Type
Dl,as owner,.r me prapanr.or nor m,pmyeec who wingex n:mem t�le.olnnp.In,udon, 7 _.
will do be wad:,and the sauaure isnot imehdal tar liberal for,mite(Sew.Trail ,
•p• Bu,iae,,alta PmCexsi n,Cale:The Cantraaods Livens Law lac,out apply Plan � uired Re Inspections
fP'Pny Who1 ld' notion,- II d i d -h workh himself
"
Required p
...through h' ply Provided Ibruch nprovemnl tof'nenddne 502^— FINAL PLUMBING ENERGY .
offered 1 I It,ha II building p -tat is Id "i ane year of
mburden
enpl r In nerb ll 'Bhrverh b 1 fpovingth that rd our build or 506 — GAS TEST _
or
we
171 La, f Irohhtapf pnyamex.m:vel).o'nanenu
rgw, lmelm
eane, „lo. - 507 .— FINAL PLUMBING t
smoutl the project(Sec.9194,Business unit Profcxsiom Cnde:l The C_ontmctar's
Lnvc Law d :not apply t owner of pmpert)who Fluids p rimer,
-
Cth contracts f h projects w
x%th a naaem(s7 t d p t I the
nn t I:Liwer,der - -
0 e pt under See�. - � B&P C fonIll,reason
Owner Date'
WORKERS COMPENSATION DECLARATION -
1 hereby affirm under penally or PerRvy one of Ina following dcclemblans. -
° 17hnve'vnd will maintain it Cedibcare of Consent In df-insure for Worker's -
Cnmpensmion,w, poesidiml for by,Section 391X1 of the Labor Code-for the' - ,
perhamancc of the work fill which this permit iv i,u,al, ,+
❑1 have and will mainmin Worker's Connpensalion Insuranea,ac required by Section' ._.
391111 of the Labor Code,for the pc,linmane,of the work'tar which this peril in -
t issued.My Werker's Compensation Fortitude comm and Policy,numherum: , _ -
Carrier: Policy No.: '
CERTIFICATION OP EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE '
1'Hhi,svelimi need not be completed if the permit is far one hundred dellars ,1 -
($1(X1).leas.) , x
I eenify that in the perforaree of the work For which this permit k issued,I'
shell no[mount'any.soon in any'manner,n as In bearme xrovd to the Worker,'
Compensation Lnwa of Gilifonlu.Dm. -
APPIiaml
NOTICH TOAPPLICANT:if,after nuking Ihie Ceniliute of Exemption,yon should -
bmamtwhimt m the Worker's Q.Q Compeiti s pmv,I ms of the Loner Ctalc you mull'fimhwith comply with web provisions,ur this permit shall he deemed revokel:
r
Hgl!) acoi
' 'CONSf12 NLENDING AGENCY
'Ihmcr norm tpe ci:, t i d' gage yr a prrnnn.ore -
frl G: of the work for which this permit is issued(Sec.311e7,Civ.C.)
Lender's Nem. -
a adlhtpplet ,nadanlfat thata"afGrmtl'n _ itQIce by thmlhm -
W ee. eon .1 agree t comply with ill i ty and Amat,mdidurns,and smile P telling . - "
V to thil!b .I titan d h
noereby art..., lh
p ,rntaivv,dsc'Iy 4,even poo
r frit Ihuthme.Inendoncl pmpany for inepeetimkpnrpnses: - - .. .
E., W 1Wolu9rce In save,mdemnify and krep harndess the Clry if C.Penino against ,
H
F/] Imbilities,judgnten¢,coo,and expenses which may in any way vcrne against said
6,) 7 'City in ainneyucnce of the grnming of this pemtit. ,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued, b
SOURCE REGULATIONS. Y• -�, ` Dale,
Signature ol'Appliennl/Contfa.a,r Date 'Re-roofs 4
HAZARDOUS MA'I'LRIALS DISCLOSURE
Will me applirnnt tar rware di ilding cecupant,lom o,handle hazann
rdnns ndual Type Of,Roof. .
Is dolined by the Capeninu Municipal Code,Chapter 9.12,and the Iheilth and Slurry
Cods,
- - -
Cods,Keeton 25532'a7p - t t -
El Yes ; orvn - : All roofs shall be inspected prior,to any r`tiofing material being installed.
WitIthe ltppldralorIutmehommngoccup,;mUse Cywpinenrmdni.n,wla.11 If a roof is in without first obtaining an inspection, I agree to remove
emit h d : n tnrt,i II Iby the Bay Area A Q.1 t,M eclumit . - .
•
Distrait°Y °No us> all new materials for.fnspection. Applicant understands and will comply with
all non-point source regulations:
I ...d the Indardo,material, tx hade,CI pun 695 of the California Heallh&Safety Cd Seer,ns 25505 5533 and 255341 ndenL Wmill , a
ifthe btldingIll c[mmay'baye a lenanl,matin N uy respansbibty to nodfy the - • '
omupant of the requlremenu which mnsl be nut prior Ili Ixmeau,of a Cenifr of "
ccupan r. -.
. •'Signature of Applicant ..Date e '
owmm,n atuhode d agen -Date ' All roof coverings to be Class"B'.' or better «
>
.OFFICE.