00050198 L r;
Via'�JTY OF'CUPERTINO PERMIT No.
aIRUILER A-DIVISION •ON RA TOO R I�NFOO R(MAxTIOO N:
PERMIT d605d
HUI DINGADDRAsS: (/C/
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I SANUARYNO. APPLICATIONSUBMITFALDATE
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OWNER' 1 Mp D p /y i]
OX�a(//Y�� /, /Y� /(� //�/� ///q� NIC CONTROLM
ON,
/f'0 J /� (i{//� N1,9 ,Y i`(/V .' _once' , 1015 ❑.
RCHITECfIENGRIEF.R
ec ` 3 8'
V
I-�:^ v LICP,NSED CONTRACTOR'S DECLARATION
Z-O v'- I bercby affirm that I Am licensed urner provisions of Chapter 9(commencing .• Job Description
.
6666q60�� w;�Salirand,1 of Di j}ion?ofjhc LucsiNnr and Pofwims adc.WmYlittnse' G.Y�ST�NC2 (a/OUO
k J in full(orceayaMeRec�L('(,1�Lv—J—
C.3o. Da Qum 12D10G 67 9,54*AL7 yS'}N' i/1lCvt65
�NgO A .lWl S DE
uft,.CLAR 0 �GUI/,��/I/ ' ✓J/.- ✓J�QO/'-/ ND.• �3iIS.�
q:n o
1 udenud my plans.hall be used u publi rcc1
1 o( licmsed Professiowl
n. u OWNER-BUILDER DECLARATION
i 1 bertby.Posen that I am exempt from site Coateactoes 6kenw Law for to - -
bllowing season.(Section 7031.5.But=$ad Profwions Cade:Any City or County
which rmoney a pemot to Conswet,slier,improve,demolish,or mpair any sanctum Sq. Ft. Floor,Area Valuation
pricemits isswnce.also requves me eppliomformch pemtil m fileuignedamtement
Net W is licewd puswnl to the provisions of one Courtrooms Licenu Law(Chelates 9 t/
(commeneingwimS«eon7OW)ofDivision3oft BasiMuwP fasiomcade)w . APN Nu OccupaneyType
Nem
al W is exempt therefrom and Lha Wait for me Alleged exemption,Any violation of
Session 70313 by any Applicant for a permit subjects the applicant m e civil awry of
Qa Nan Eve hundred dollen($500).
more R.
Las awoer of Ne propenY•or ser employcev wise wagesatheirsole compensation, Required Inspections
will bo the wort,adtheanuctme is no intended onoBetd for We(Sm.7014.Buuness
and professions Cade:The Convector's Lt..law dao nm apply An en owner a
propcny who builds or improve.thenen,and who does such work himself ce through0001,
his own employers,provided that such improvements ssc'not intended or offered for "'
We.If,bowean.Lha building or io,somoseent is sold within oft ycaofmrngldon.she
more,hoilcho,will have me burden of proving Nat ha did nm build or improve for ser- t ,
pee of ssle.), t
❑1,As owner of the propenY•sen exclusively cormscsing wise licensed conmcson An
C.Aleacl me,project(Sec.7044,Bonier.ted Professions Code:)The Connector.Li-
cense law does not apply to en...at of property who build.or winds.thereon,std O
whocontrau for such projects with....too,)licensed pursuant in me Canuactora
License Law. O
I um exempt under Sm. ,B&P C for this recon _
Owwr • Dam—
WORKER'S
an WORKER'S COMPENSATION DECLARATION '
1 hereby affirm under pew)ty of perjury ooe of Ne following declarations:
1 Mvh ed will meinmip aCenificatc of Cwsenno relf-imme fmwmkcb Compn-
avian.as provided for by Section 3700.1'me Labor Codc,for the pertortwoee of Ne
work
for which this permit is issued
have and will maintsin Worker.Companmtion[.A..,.m required by Section '
3700of Ne LAW,Code,for me p obouance of du work for inch this permit is modest.
Career:
Poky NoYn/.) 7_//T/ %/p
UMCATE OF E.%Eh1P'IION FROM WORKERS'
COMPENSATION INSURANCE
(This mica need nm W completed if the porous,is for me hundred dollen(5100)
o kat./ se
I employ
any Nat in in my man n r o as t becomexuk for wMce t top a Worlossud,I moll
not employ any person in any manner so as to become subject m Nc Warketi Compcn- A -
sati Taws of California.
ia.Data
ti
Applicant '
NOTICE TO APPLICANT.Wori IL Beet Conking this Cenifiwn of Exemption,you should
become subject y the Warh'e Compensation provisions of Ide labor Cole,you most •.
(onhwiN comply with such pkoviaians m this permit a1Wl be dsmd revoked. '
CONSTRUCTION LENDING AGENCY
0 Q 1hhereby affmiNw
atthemisaconsctiion[endingagencyfortheperfomwceof
Z the work fon which this pemtit is issued(Sec.3097,Civ.C.) '1 .
Lender.Name '
W I certify that 1 have,nod this application Ad Aute informational the above information is
0. 0 coned I Agra to Comply with'ali city ad county ordinances Ad sate laws relating to
0 Z. buildingconswction.And handy mmorize repreaenutives minis tiny m mulmon me '
U 0 above-mentioned property for inspection purposes,
W F (We)earn to save,indemnify and kap haemal.the City of Cupertino against 7
0 U liebiliees,judgmnts.costs and expenses which mayinmyway ammemminslmid City
>s W in comequexe of the granting of this permit.
[� Dr APPLICANT UNDERSTANDS AND WI LL COMPLY WI 1'II ALL NON-POINT , -
V Z SOURCE i UL.KNONS.,
' arc Applicanontnctm Dam
HATARDOUS MATERIALS DISCLOSURE
tali the:applicant on(uture Wilding occupant Ran or hadle baeallona maunal Re-roofs
As defined by Be Cupertino Municipal Code,Chapter 9.12.And she Benito and Safety � C Of ROOF
Code,Section 25532(a)7 'T ��A/, - p -
El Y. Og„o
Will the mlpliunt or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing:material being
emit hezudous Wconumiwnts w defind by the Bay Arca Ah Owliry Muagement installed.If a roof is installed without first obtaining an inspection
a e4 I agree to re ove.eall n aterials for inspection. Applicant
❑YCA o - g gw-m
Ihea rtad h.aardtmri.lA regiiremnnaadergba usti.95nfineali. unders n iyd-willcl comply with all non point source r///egul'attons.
tomo Health&Se I Code,Secvons 25505,25533 and 25531.1 udeuund that if me L/� /jArj S
Wilding dos n tl Mveauns Also it is my ruponsibilirymnotifY me occupant aJ /V(/
of ds ion mwt out price to mutme,of a Conifins of
Zg i ature App I Date
rizd age Dam I -
Y All roof coverings to be Class"B"or better
OFFICE
880 Dubuque Avenue
e-solutions for the contracting industry South San Francisco,CA 94080
(888)88 CLERK
Building Permit Application
klerk Inc. To: Building & Planning Department
:e: Scott Waterbury City: Cupertino
(650)624-0426 Phone: (408)777-3228
.,her: 1-(877)846-5888 Fax Number: (408) 777-3333
Permit Handling Instructions
X Please Fax Permit to: 1-(877)846-5888 Deliver to job site at first inspection
I will pick permit up at the Building Department in 5 days X Please mail to Contractor address below
Other: please email permit to: permits@netclerk.com
Contractor Information
Company: SHELTON ROOFING Worker's Comp#: NWA-0152063-00
Contractor: State Contractor's License# 261091 C-39
Address: 1988 LEGHORN STREET Credit Card Information
City: MOUNTAIN VIEW,CA.94043 Credit Card Number: 4246-31124172-3904
Phone: 650-961-7699 Name on Card: NetClerk Inc.
Fax: Expiration Date: 04/02
,mail: sheltonroof@earthlink.net Visa rz MasterCard
Comments:
Mail
Authorization forms:
"Agent Anthoriratiaa^-By complating and returning the mfomutioe below,
Credit Card Authorization you authorize Net Clerk Inc.tow now agent on your behalf
Company Name: NetClerk Inc. To whom It May ronwvm:
Company Addmu: NO Dubuque Avenue Let this loue authorise NuL7erk Inc.and all curnro ly employed and
_ South San Franciso.CA 94090 authorized asroclai"of NefGerk Inc to act a.c an agent on ow behalf—
Phone: (6SO)624.0409 signingfor any and all budldingpermin and lkerrn required by our
Fax: (650)624,0402 company.
Email: twu(alnetclerk.com
Type of Card: Visa MasterCard Srocen'1i• hat{,.°
Cardholders Name: Anthony Wo-NetClerk Inc.
Credit Card 0: . 4246311241723904 Expiration Date: 00/02 Namo;iL?ANtIC.-,_�GNL(:il
By signing be low,I give NetClerk,Inc.and all currently employed and authorized associates of 7711e: 99F0re6 rdflgAlA�Cl2
NetClerk to sign credit cud authorizations for the purpou of permit applications. J`/ ` �'4J
- S � caonal'>W:QfLFTLIi<d� F _ /�/r`c
Anthony Wu-NetClerk Inc. ^ /IS II00
Cardholder's Name ignm Date