05070082 CITY OF CUPERTINO
BUILDING DIVISION PERMIT s CONTRACTOR INFORMATION
Ater.=syr
BUILDING ADDRESS: PERMIT NOO 5 0 7 0 0 8 2
10535 DEODARA DR
OWNER'S NAME: PERMIT ISSUE DATE
GERLACK RICHARD Z TRUSTEE 07/13/2005
E: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGEIFR PLUMB MECH
moo LICENSED CONTRACTOR'S DECLARATION O O O O
I hereby affirm that I am Boomed under provisions of Chapter 9(commencing Job Description
Z9 with Stedon mll%)of Division 3 of Ne Bounmand Professions Codc.md my license is
n`C,d, infull force and efrect. REMODEL MSTR BATH, REPL. SHOWER, FAN VANITY
j Z License Class Lt..N J f
Et.w Dae Comracur FLOORING NEW LIGHTING�F.'IXTURES
ca< ARCHITECTS DECLARATION pp Ins
at IuntlerstanJ my plans shall be used as public mcorrB �[ N d 'bsi'�xMG^.. . I`J.?
to (J y fI[
;as LiccnxdPnrfcssional q - 9nn5
OW NER-BUILDER DECLARATION
<F I hereby affirm that 1 am eacm,,from the Conlrac ors License Law for the
00 following mason.(Section 7031.5,Business and Profcesions Code:Any city or county
K m f which mquires a permit to construct,alter,improve,demolish.or repair any swctum fl A a A A`y'ra is r4 h l�
°-to prior m its issuance.also requires the applicant for such permit to file aligned statement
FsO In.h is licensed pursuant o the provisions of Ne Cenlrecwh Liceme Law(Chapter 9 Sq.Ft. Floof. II U (h ValuaE�6.t1000
set-$ (commencing with Section 7000)of Division 3 or th Business,and Professions Codc)tar U �T/
'yt _ Nm he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by my applicant for a permit subjects use applicant w a civil penalty Of APN Number Occupancy Type
not mom Nam five hundred dollars(M). 31630045 . 00 P Y YP
El 1,as Owner of the property,or my cmployces with wages as deir able compewuan.
will do the work,and the structure is not intended proffered renal.(Sec.7044,Business
and Professimet Code:The Contrsswrs License law docs not apply in an Mau of Required Inspections
property who builds or improaes t hemmn,and who doeaauch work himself or through his
own employe=.provided that such improvements are not intended Or offered for sale.If,
notion,due building or improvsmam is sold within one year of completion,the Owner-
mottor will ban the burden of proving Net he did not Wild or improve for purpose of
saic.).
X1,as owner of the pmpeny,mo exclusively cmmuaning with n
licensed conuaors to
X-truct Ne project(Sec.7044,Business and Yrbfwions Cmdc:)Mie Commove,Li-
came law docs not apply W an owner of propcnywho Wilds or improves Nemon,and.
who contracts for such projects with a comae or(s)licensed pursuant W the Contraceori
License law.
01A esem�)gf der Sce. .B&P CC for
TN�is�reason
Owner_ !/I.,/. e/ Data I3 Tu�0S
V WORKER'S COMPENSATION DECLARATION
1 mby afNm under Pointy of perjury one of the following declarations:
1 Ishan and will moinuin is Cenifi=w of Cense.te self-insme foe Winker'sCompm-
sation,0 provided for by Section 37M of the labor Code,for Ne performance of Ne
work for which this IOOI l is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 oftic labor Code,for dm perforce om of be work for which his permit is issued.
My Werkcrs Cmmpensetion Insurance carrier and Policy number are:
Career: Policy No, _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(TTu rection good not becomplcwd if ih Permit is forma,hundred dollars($Im)
or less.)
I mnffy Nat in the performance of on,work for which this Permit is issued,l shall not
Law =any person in any man � o su ctAo tlwWorkeri Compensation
lawaof Calif= n n T/ y
Applicant M
NOTICE TOo ANT. ter jiltaking this C.nificam or Exemption,you should
become subject in thc Worker's Compenuuon provisions of ft labor Code,you muss
.J O foMwifh comply with such provisions or his Permit shall W deemed mvoked.
Z Uj CONSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a constructing lending agency for the perfirrmarcc of
a the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
7 Z Lenders Address
U 1..fly that 1 have read this application and mule Nat he above information is
correct.1 agree to comply with all city and county ordinances and sok laws miming W
0U building Conswction,and hereby aunhorim representatives of this city to enter upon the
rW
move-memionetl prat for inspection purposes.
(We)agree to marc,indemnify and keep harmless the City of Cupertino against
tF-t rjj liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the grami.,of this permit.
APPLICAN�TpUpN[D�ERpSTqA�NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE R//{/ hN /YGltsl/'A I'3Ty�a5
Signature A p' nVCOnuacwf Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE - Type of Roof
Will the applicant or furore building occupantawre or handle hamdous material
as defined by the Cupertino Municipal Code,Chapter 9.12.aha The Health and Safety
Code,Section 25532(a)? �a�. All roofs shall be inspected prior to an roofing material beim
0y❑rens W Nm P P � Y g g installed.
t a liani ter furrrm'''rc building Occupant mere< m If a roof is installed without first obtaining an inspection,I agree to remove
Willrap 6equipment or devices which g
..d hanrdous air contaminants as defined by the Bay Arta Air Qualify M itagcmcnl all new materials for inspection.
District?
C]Yes )KN.
I have mad the hannio smaterials requirements under Chaptei-6,95 offhc Califor
not HotlN&SafctyCodc.Sadorir 25505.25533 mv125534.1 understood thuifdm Wilding
does not etanclul,have a u nam.Nat it is my r=ppmibility W notify the taupe.Of the
require:(/��jah asst elpri toi.gymbecoraCCNfcatcofOC;AmCy. Signa[ureofApplican[ Date
3 wL�
Owner r a Ih ive0 age. Dale All roof coverings to be Class"B" or better
'