22432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
s
Building rraee ldentl(IsaHan IFR.WTNO.
Building Address: I"I f"I A /"�n
2 111/ 7 6� AJ e.v V ew t pA c- GG43G
G(' • m '2 s7- �J 7� CITY OF CUPERTINO-BUILDING DIVISION
ren. one: �
�' ° L / pN� APPLICATION /PERMIT, 8 qL
CONI GT1r0.✓ �Ip IO BNLDINGELECDUG MUMBINGMECHANICAL CATEGORY CONTROL#
rARect/Engles. Ue.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aaae.Y .O. oX O ,., CULUU
.4 f PERhaTTssuAN� � ❑ n
LICENSED CONTRACTOR'S DECLARATION aL` '=
Ihereby affirm that l am Bcenaed under provisions of Chapter 9(mm a APPLIANCFSRESIDENTIAL JOBN
Ingwlth5eet1on700(l)of Division Jofthe Busteesand ProfestmuCode,and my
hernDate V In fund to d efletl. PANELS
License Cht,C14, Lk.1
- Date_ /'/ Comnctor '
ARCHDECP ECLAR)kTION -1000 AMPS
q�v WceW fly I understand my plans shall be used as publieeecvds. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
FS`uCrj Limeted Pmf.iavl SIGNS ELECTRICAL
<�<q, OWNER-BUILDER DECLARATION SPFGTALCRCUR/MLSL
F. I hemby afOnnthat 1.m,.,.FK fenn the Comradm'a Lbenae Law for the
followle g ma°an.(Sect/on 70715,Business and PmleWona Code Antl or
Kg o nywhkh qubeapem omro ua.a ter,mpm t,aemoWh.orrtpar TENIRMLTERORPOLEINSI'.
4 anystructurt prlmtoit.L+nuance,abo eequimthe appBontfce such pemdt to POWER DFVICFS
file a signed statement that he b Licensed pursuant to the provive ns of the
O6 rE. ConteanoY°IJcerue Law(Chapwr9(mmmeneing with Secfbn 70W)of Diel-
F30"J mnJolthe Bustne dPmfembroCode)orthat hebeaempt(herefromand SWIMMING FVIX.ELECTRIC VALUATION
the basis for the alleged a°empttan. Any violable.of Section 7m1S by any
ag « appDcentforapemdtaubkcb e.pplk ttoa GWlpemhydnmm mtlun OITIT.E7SSWHCHFSFPTURFS
live hundred dollars($500).
�n ❑I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFT. aEF
IDRITS TYPE CONSTRUCTION
menpeesation,will dothe work,and the nroavrt hent Intended or offered for
� A,O sale5cc70/4Bu.Ines.ndPmfesiae Codr:The Contractors Lloense Lew ,
[Pj$$ don not apply loan owner of peapertywho builds orimpeaves themon,and CCeROUP RFS UNITS
CC whodoeaucbwmk himecBorthrough hlsownemPloyees,pmvidedthatuA
improvemed.are not Intended orofferd far sale.If,however,lhewiding or, 'TOTAL:
hnprovemcm Iswldwt hln oneyearofcomplrtlastheowner-bu Mrrw0l have
�rden of proving that he did net wild or lmpmve for purpose of sale.). QTY, PLUMBING PERMIT
L n owner of the property,am exclusively�tmeting with Ikxn.ed LOODTDNE MNaontraetars to conaud the projod(See.7014 Busher and Prdexbns Cade: PERMIT ISSUANCEThe Contractors License Lew doe nd apply to an owner of nroperty who
wilds or Improve thereon, and who mmrtm for=6 pty)eN with a ALTER-DRAW k VENT-WATER(EA)
�QW�ctor(.)0cenrd punwnt mtheCmtnctd.Llcensel�w.
BACK FLOW PROTECT.DEVICE FEE SUMMARY
U 1 am e.em t under Ser_ B k P C for this reasonOUTSIDE
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N ' 1
Owner - Date RECEIPT l
WORIQdAN COMPENSATION mrifiION DECLARATION FD(TTIRES PER TRAP SCHOOL TAX Y N
l ❑1 hereby ml that I have•ce Rinne of consent to opy-inurc,ora RECFI7#
38W L bol Worken'CompenrBanlwrance as¢etBlad nspytheeed 6ec. GAS EA.SYSTEM-1 WCI OUTLETS, PARKEEE Y N
3800,LbC) / _ - RECEdT I
Pdky# GAS EA.SYSTEM-OVER#(FA)
� nAY t'�' ( eft L BUILDING DIVISION FEES
agLRCedlned ropy b l d wfurnished. GREASE/TNDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy,la filed with the dry InspMb.dlvWon.
CERTIHGTE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
RMsaedlonneed
COMPENSATION
OMPENSATION INSURANCE nane hundred doMan SEWER-SANITARY-STORM EA7DUF �. Date Recti f#
(flm)ar l`r') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cenoy employ
tan p pe.1,any m work so as to h this pemdt is laved,
1 dull ,' employ any prance.In any crooner at n to berome abject to the WATTRSYSTT'ad/TRFATThG
Workm'Compensatbn lrweof Ghfomia.Dote PAID
OZ Appllmt NEW RESIDENTIAL PCMB. SQFf. Date Recei t#
Z O NOTICE TO APPLICANT:M,after making this Cenlfleale of Exemption,you
skald become subject to the Woeten'Canpenatbn provision of the labor TOTAL:
Crf/] Code,you momfethwkh comply with sock provisions or this permX Nall be
Q > dermad revokBed. _
W a CONSTRUCTION LENDING AGENCY ISMIC FEE
CL Iheeeby.fnm,thattbem B.meWeuctimn lendmgageeeuuyy fart he preform- TOTAL: ELECTRIC FEE
7 Z aner ofthe workforwKeh this pernot b E.ved(SK 3097,CIv.C.) / D0
00 1 rul°rs Name PLUMBING FEE 17. Q-a
'LL F- lender.Adder,. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W w
I mAfy that l have read thin appllcatenand state that theavr Lerw
Jorion
lamact.I:geeetoc=plywith°Bc"awmantyordmm=aaa
dtelaws PERMIT ISSUANCE FEFSPAID:
Ill. re
Mating to wilding mewructler,and hereby authortre mprexntadves of this
Z dry to enter upon theawscmentbrcd property fee inpe Han purposes." ALTER OR ADD TO MECH. DBI¢ Reeei t#
(We)agree to save,Indm
edfy an d keep harmless the City of Cu pertIno
ag.bet habWths,P d reiw,mstnand e.pensn wheherayleanywayaeerue AIR HANDLI NG UNIT 10,000 CFM) SUBTOTAL:
ago stay ryc�.(the gnedIng dthla permit.
�//„ Arte HA NDUNG LINTr(OVM 1 QOo0 CFM) CONSTRUCTIONTAX
rt of Appuo.t/Contractors Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATH R DOUS MATERIALS UI SCLOSURE
Will the sFEE.morfutom w Ilding omrpart store or hard le haaardeus HEATING TWIT CM l Of1,ODD BTT) Date RCCei t#
material n defined by the Cupertloa MuNdpal Code,Chapter 9.1Z and the
Health and Safety Code SSeetion 75532(.)1 HEATING UNIT(OVER 100,000 BTI) TOTAL: •DO
RYns uNo
Ml the applleantm tun°wilding occupant use equipment or devees VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eMt haeaedous sir contaminants as deeud by the Bay Arca Air
Quality Managemcm Doorlet7 BOM.ER-0DMP OHP OR I W,IX9 9M ISAIQ
4Ye I:�No
have mad the harm materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
understand
that if th ASafety Cods Sectbns75505,ve atnnt,that 1 IUf t g N� ^
undmtand that if the wilding doss nwtamntty luveatenanL tbatltbrery h'LW RESIDENTIALMEIN. SQFT. R} h �f �J�
res hyto.oilytheottvpantdtherequlecmema which nwst be eeai
prior tototbaruaeuedaC<nlflate of Oc pang.
Ownerorauthcriud agent Date TOTAL ISSUEDBY. t
OFFICE COPY
SEWER CONNECTION PERMIT SERIAL
P4"") 15152
CUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No.............. Lot No..............
20065 Stevens Creek Blvd. A.P.N. 13k.-S.2 4a..... Pg.../.�?.... Par.?.9.0...
Building C
Cupertino, California 95014
Phone (408) 253-7071 Date.. . ....1..........
( �...................... 1991.
The undersigned, being the owner(or owner's agent)of the property located at ........................................................
...........� .�.7.....Ca.vc�xnLv.iexJ....�.�u... ..�...1-� .k0k^..4�.... .................................
consisting of the following TYPE OF BUILDING:
Residential: Single family.....[?..... Multiple............ No. Units...........
Commercial............ Industrial............ Other............ No. Units............
does hereby request a permit to connect to the sewer system of the Cupertino Sanitary District.
In consideration of the granting of this permit,the undersigned agrees:
1) To comply with all existing regulations and Ordinances of Cupertino Sanitary District and all future regulations and
Ordinances which may be adopted.
2) To maintain the house sewer(that portion of the sewer within private property)and to provide access to the lateral sewer through
a cleanout raised to grade at the property line or at the limits of any existing District easement. (Note—Detail J)
... Building Depart-
ment
e rt-"
3) To acquire a permit from the .... ..�.c.t r) r .... �............................ g pa
ment and obtain inspection and approval by saidilding ) rtment prior to covering of the work or use of the sewer.
4) To first expose!and inspect for serviceability the lateral sewer prior to starting construction of the house sewer.
Property Owner'sName.?tv.v..q..7.tJoHi/.(��y............. Telephone....Z.S7-./.7 Y./.......................
Mailing address if /
different from above.....�j..�! ..!. " —..........................................................................................
By/ ....................
❑ A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above
property. (Note—See Detail 1)
FEES:
Connection Permit Fee o G
Sewer Service charges to June 30, 19 .,$.. �.�G...../mo. x..!!!.mo. -> ....
Inspection Fee for backflow protection device
OU
TOTAL $ Z
00
Seceipt — .... acknowledged and permit granted! MARK THOMAS&CO. INC., District Manager-Engineer
By,,W ........
NOTE.See Details on other side of this permit -
-- /
CUPERT/NO SANITARY DISTRICT
NOTES: All valve, in be see...laid and maintained by Property owner.
Overflow point at least twelve Inches(12') below lowest finished
floor containing plu birl
Kelly Valve Installed at Property Line to be recall, removable
for Lateral Sewer maintenance.
At
E
J
°' Frni h or_Level 5
d °' E Nelly VOHe Rni,h Floor Level 5
Finish Grade
-
Kelly Valve -(E a'
Wive Access BO, —
with Vented C / Valve Access Bo, mn —as
Backwater Valve
- FSO W_r
i•
Figure I Figur. 2 Flgure 3
Kelly Valve- Below Surface Backwater Valve-Normally Kelly Valve-Above Ground
llntallation-Shown at required Installed al shallowd,t Point IretnllWim-SMwn installed
Property Line Clemmul. plan, House Sewer bete... close to building. •
Property Line And bolding,
DETAIL
STANDARD BACKFLOW PROTECTIVE DEVICE INSTALLATION I
Distance from it to be as
doe. as pracllcabld.
J
Rdmavaal. Cleanout Mug
d Finish Grade
Wye far Riser
Sewer intainaut Boa with Lid to be accessible
Short length and maintained by property owner.
i Riser Pipe
Adaptor apaptle, VB Bend
OW n
Laical Sew Nouse Sower
17GF@`Ciinlmum nope determined by Building Department.
Lateral Sewer Cleanoul to be some
size as Lateral Sewer.
•
DETAIL
STANDARD CLEANOUT FOR LATERAL SEWER J