29968 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
91TY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. !� (] ("�CO
(\BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. L J J v O
BUILDING PROJECT TDF,NTIF ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDATE
jmw
SUle
W
OV PHONE: C O 'S
T I
ti SIC CONTROL#
C T C'I iNGINE tN: LIC NO: RIS$ ❑
I L
CONTACT: PHONE: BUILDING PHRMIT INFO
❑ Consubant Fees Paid by Applicant(Initial) BLDG ELECT PLU MECH
❑ ❑ ❑
LICENSED CONI'RACFOR;S DECLARATION QTY ELECTRIC PERMIT FEE
]hereby off r.a Nm 1 ala lixi ower provismr. A Chapter 9 o—comendag JOB DESCRIPTION
Z with Sec11on90XM)of Diskion3ofthe Bu.sinessand Prof .h Cult and lfjicenseis RESIDENTIAL,
F in full force mJ of t. PERMIT ISSUANCE
,emu,�� License Lich ❑ShUWL E3 KITCHEN RF'_MOUF.L
` APPLIANCES—RESIDENTIAL []ADDITION C3 PLUMBING RE-PIPE
w nmU Lie ff mor
m ARCH]I'It DECLA tAT OI PANELS ❑MULTI-UNIT ❑STRUCFURAI,
Z~p y Z I ders d m 11 be try as pobli do MODIFICATION
OZ Q racor. UPT0200AMPS ❑INTERIOR C3 CHIMNEY REPAIR
F t3.F.; lsrofmaiwal 201-IIXMAMPS IMPROVEMENT
WNF.R-BUILDER DECLARATION OVER Fast A? ❑tlATH RF: De /REP )EMOhI'f10N
6 1 hereby affirm thus I am exempt from the Cssions rz Any c ty o for the
xL�d�dU %hichingreresa Permits 7031.5.consumer.
altcss and improve,
demolish,
Co de:Any city or County SIGNS HLECfRICAI. ❑OTHER
ft13 W vFi which requires a permit to ttire,he.ul¢a i t for
demolish.or repair any swment
prim mustssuance.tits.re qui res heapplicantdox mchpemteis Limasle a Low(Chapter9 SYECIAI.CIRCUIT'/MING.
EW} thatrm Islicensedpursuant to the of Division
of of Contmcmrs Licensenew,Code)r9
ty ce that heisngwiNSerefrom and ofbasis for of Neeged exempt Professions Code)or TEMP.MEf[ROR POLE(NST. COMMERCIAL,
6 o C that he is exempt tan,applicator
li and the basis for the alleged exemption Any violation of El NEW BLDG/ADDITION ❑DEMOLITION
m section 7031.5 by enY upplicam form permit subject.,the applicantmaevil penalty of POWER DEVICES ❑THNANT ❑FOOD SERVICE
�=0 oat mom than Eve hundred dollars(5500). IMPROVF.MI?NT
❑ baso%hero(the Mopeny.ormyemployeeswlNwagesas Neirsolecompersation, SWIMMING POOI.ELECTRIC
$a p. will dhework,and thesre is not intended oroRceed fnrmle(See.]W4,Business ❑OTHER
wmmo
trI w and Profession.Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not imm�dw or offered far NEW RESIDENTIAL ELECIR 'Q
sale.If,however.the building or improvement is sold within one year ofcnmp]etion,the SQ.FT.FLOOR ARfA USQ.FT
owner-builder will have Na burden al'proving that he did nnI haddo,or improve for par n
Pow of sok.).
1,as owner of the property,am exclusively Contracting Who hic nsw contractors to TOTAL: A'
construct the project(Sec.AH,I,Business and Professions Code:)The Contractors Li. JUN 3 1996
came Law drw.mrn apply m m osircrafproteny no bnikkor improves Nareonand QTY, PLUMBING PERMIT FEE
who contracts for such projects with o Contranoms)licensed pursuant to the Contractors
LicensemexLaw. PERMIT ISSUANCE CIyI Uf II
(] laemptunder Sec. ,B&P C for this..,on L NtYaIQVp
ALTER—DRAIN&VBNT—WATER CA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby ofirm under penalty of perjury one Of the following declarations:
Ihuve:md will muinwin aCcnilicrm of Gmsenun self-insure for Worker's COmpem DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPECONSTRUCrION
sation,as provided for by Section 3710 of the LMrr Code,for the performance of the
work for which this permit is issual. FIXTURES—PER TRAP
1 have and will maintain Workers Compensation Insurance,ea required by Section
O X1afthe l.nhnrCode,I'mthu perp{{{manor of sire work for which Nis permit rs issued. GAS—EA.SVSTF.M IINC.40UTLETS OCG GROUP APN
My WoryuC Com sai, Inn er and Policy nu GAS—IiA.SYSTEM-OVER 4 IF A)
Cartier
CF.RT]F CATS OF � EMPf]ON FROM ORKE S' GREASE/INDUSTRL WASTE INTERCEPTOR .
COMCOMPENSATIONINS INSURANCE DUILDING DIVISION MES
Ilhissection need not the cmnpletw it he permit is future hundred dollars(S 1M) GREASETRAP
or less.) PLANCHECK 12131i
I certify Nat in the performance ofthe work forwhich this permit is issued.)shall SEWER—SANITARY—STORM EA,200 IT.
not employ any person in any manner ser as to become subject to Ne Workers'Compeer- ENERGY FEE
O Z sation Laws of California.Date WATER HFATER W/VENT/ELpC`FR GRADING FEE
Applicant
nt NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should WATER SYSTEMITREATING
F^ ^ become subject m the Workers Compensation provisions of the Labor Code,you must SOILS FEE
{ll forthwith comply with such provisions or this permit shall hedwmed revoked. WATER SERVICE
Q
p' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
V 0 thereby affirm that there is construction lending money for the performance of Dam ReceiplX
the work for which thin permit is issues(Sec 9199,Civ.C.) T(yI'AL:
Vlenders Name
{t.1 Lenders Address TOTAL:
a 1 certify that 1 have read this application and state that Ne above information is BUILDING FEE
M correct.l ague to ttmtply with all city aad county ordinenees and ,are law.rdmlng 11, QTY. MECHANICAL PERMIT FFF
L) Z, building construction.and hereby memorize repccenmtives of this city to enter upon the SEISMIC FEE
above-meatinned property far impemion Purposes. PERMIT ISSUANCE
(We)agree mauve,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiahilmes,judgments,costs and expenses which may many way oenmagainst said City ALTER OR ADD TO MECH.
PLUMPING PEP
consequence of the granting of this permit.
m 'T DERS D. AND WILL COMPLY WITH ALL NON-POINT UNAIR HANDLINGUNIT(TO 10,O)OCFM) MECHANICAL ME
SOURCERL III
AIR HANDLING UNIT(OVER 10.(00CFM) CONSTRUCT]ONTAX
ata 1ApphramA_ era or Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOU MATERIALS DISCLOSURE
Will theapphemrt or mouse buildingrccupuntemre or handle haznNous melenic HEATING UNIT(TO 1W.00d BTU)
as defined by Ne Cuper ino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scctian 255320)' HEATING UNIT(OVER I00,IX10 BTU)
�Yca ON. VENTILATION FAN(SINGLE,RESID) PAID
Date Receiptp
Will the opp]iemt or furore building Occupant use equipment or devices which BOILER—COMP(THP OR 100.WO BTU)
mit hazaNaus ami
for comanants as definrd by the Bay Arca Air Qmlity Management TOTAL:
).ural BOILER—COMP(OVER 100,000 BTU)
Yes ❑No
I have matt the hazardous materials tequmiler iler Chapter 6.95 of the Cali- AIR CONDITIONER ISSUA E
Boom Health&Safety Code.Sections 25505.25533 and 25534.I uwcrstatd that if Ne NEW RESIDENTIAL.MECH. SQ.FT.
building Nes nor catrnnly have a ranme.thus It is my responsibility to notify Ne occupant
Of the mquimmctes which mast be met prior to issuance of a Cenificme of Occupancy.
Owner or contacted agent Date TOTAL: ISSUED BY:
OFFICE
PERMIT P-*347
CUPERTINO SANITARY DISTRICT
Santa Clara County
20065 Stevens Creek Blvd., Bldg C, Fax (408)253-5173
Cupertino, California 95014
Phone (408) 253-7071
CONNECTION PERMIT
R.O.S./P.M./Tract No.��c>'° Lot No. 2 Z
A.P.N.: Book 5 2 (o Page-Ij—Parcel � du n e
2- Date I
Property Owner: 64.4 /,,e. —/-4
Mailing Address: /-7'c5a4-- _
(If different)
Telephone:
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make/application for connection of the property at:
eL Oa"X�d
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family X ; Multiple Family ; No. Units
Commercial , Industrial ; Other ; No. Units
do hereby request a permit to connect to the sewer system of the Cupertino Sanitary District.
IN CONSIDERATION OF THE GRANTING OF THIS PERMIT,THE OWNER AGREES:
1. To comply with all existing Ordinances, Rules and Regulations of the Cupertino Sanitary District as now or hereafter amended.
2. To maintain the House Sewer(that portion of the sewer within private property) which includes a cleanout (raised to grade and
accessible) located at the point of connection with the Lateral Sewer (that portion of the sewer in the street right-of-way or
District Easement). / /
3. To acquire a Plumbing Permit from the / of Zu je- I S" Building Department and obtain
inspection and approval by said Building Department prior to covering of the work or use of the sewer.
4. To first expose and inspect for serviceability the Lateral Sewer (that portion of the sewer within the street right-of-way or
easement), prior to starting construction of the House Sewer.
5. That this permit does not constitute a request for the issuance of an encroachment permit for sewer construction in the
street/public right-of-way of the agency having jurisdiction thereover.
6. To call Underground Service Alert(USA) 1-800-227-2600, at least 48 hours prior to starting grading or digging operations:
SPECIAL PERMIT CONDITIONS(Exhibits):
❑ A BACKFLOW Protective Device shall be installed on the above property by the owner. Type of device and installation
shall comply with the Plumbing Code Requirements of the jurisdiction shown in 3 above.
FEES: r7/
Connection Permit Fee: C10� $
Sewer Service charges to June 30, 19G/ b— e
g lf�, $ mo. x Mo.: $
Inspection Fee for backflow protection device: $
Considerations and Restrictions of this Sanitary Sewer Connection Permit with attached Exhibits (when noted), are hereby agreed
to and acknowledged by the undersigned Owner(or Owner's Agent). Failure to comply will void this permit.
_ a
Acknowledgment:
Owner's Agent:
(print name)
�U
Receipt of$ r acknowledged and permit granted.
MARK TH MAS& CO., INC., District Manager-Engineer
b
Note:See Details on other side of this permit.
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
w not to exceed five IS) feet.
c
J
Removable Cleanout Plug
son
0
CIL Finish Grade
Wye for Riser
Sewer Cleanout Box with Lid to be accessible
and maintained by property owner.
Short length Riser Pipe
Adaptor coupling 1/8 Bend
Lateral Sewer I House Sewer
Lateral Sewer slope House Sewer slope
determined by District I determined by building department
— CLEANOUT TO BE SAME SIZE AS LATERAL SEWER—
Notes:
1. Distance from the property line not to exceed five(5')feet.
2. Property Line Cleanout, Lateral Sewer Cleanout,to be same size as Lateral.
3. The maintenance of the Lateral Sewer Cleanout is the responsibility of the Property Owner.
4. House sewer minimum slope determined by local Building Department plumbing code requirements of the
agency having jurisdiction thereover.
TYPICAL BACKFLOW PROTECTIVE
DEVICE INSTALLATION
TYPICAL BACKWATER VALVE TYPICAL KELLY VALVE INSTALLATIONS
INSTALLATION Judedlclional ReetHa,ians
Accepted By All Jurisdiction[
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade Installed Below Grade Installed Above Grade
Shown Between Street Right-of-Way and Building Shown At Property Line Cleonout Shown Adlocenl To Building
Reauiree Regula,Mainlenonee Reguiree Minimum Maintenance Rlaeirtl Minimum Moinlenan C!
Volvo To Be Removable Valve Should Be Removable
VALVE ACCESS BOX FINISH FLOOR
da
wBvvamed Cgver
o Level of FINISH FLOORst KELLY VALVE
A. tIKELLY
VALVE ACCESS BOX EFinish Grade
Finish Grade
Z
BACKWATER m
VALVE
FLOW Al FLOW �? FLOW n/
Notes:
1. The Backflow protective device to be located on site in the house sewer.
2. The type, location and installation of the Backflow Protective Device shall comply with the local Building
Department plumbing code requirements of the agency having jurisdiction thereover.
3. Device to be accessible and maintained by the Property Owner.
4. If a Kelly Valve is installed at Property Line, it is to be readily removable for Lateral Sewer Maintenance.
0 -