25286 APPLICANT TO FILL IN INFORMATION WITI IIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ..".."Mi-.31.1u,IR ,A, . PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 25286
BUILDING PROJECT'IDEN'I IFICAI'[ON
BUILDING ADDRESS: /�/ �.� SANITARY NO. APPLICA'TONSUBMUTE
ALDAT
IIOO y ✓5/ r L 0r• UNIT# LOT
4AMg� AMCN : C t PIIpLPjF`� N�T)RACfpf,R'S NAME: ,L.LCN
r01, V ti T�� ^1 V Ids P� Iln� }� 3S8 N/C C11NTEOL4
RCHITI:CT/ENGINEER: LIC NO: �APREsxsax �-� F-1ONTACT: PHONE: I''` BUILDING PERMIT INI'G
QTY. ELECTRIC PERMIT FEE
'
BLDG ELECT PLUMB MEC11
P17RMIT ISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESC ITTION
Op.y lhcrcby pip.,hot l not licensed mdcrpmvi,mmofChupla9(cammencingwinh
u100 Section 7")of Division 3 of the Business and Professions Code,end my license is in PANELS
Fye mg. full force and effen.
FZW LicencC Lic.p UPT02MAMPS
In Contractor 201-1M)AMPS
FyZ ARCHITECTS DECLARATION SQ.F1'.MOOR AREA $/SQ.FT.
06n_ 1understand plans shall M usedaz public records. OVER IOOIIAMPS
OZ—❑
W SIGNS ELEM RICAL
Licensed Professional
�mm6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
°JO,U 1 hereby affirm that 1 um exempt from the Commaors License Law for the
followin (Section 7031.5,Busim.md Professions Code:An ci t I HMP.METER OR POLE INST.
gators a.(. Y Yotruony
F'a 0¢
poplin
requires issuance,permit re cunswct,after.pplic improve.demolish,or ream,any sticture
Boothe.is lcensedulsmenuirts theapplicantof
ohesuch Cmdrium,v file aLiwerigned atwemmr POWER DEVICES
him M1c is licensed pmwant to tire provisions of the Comrunor's Liccnsc Law(Chopper
W O SWIMMING POOL ELECTRIC
ddoK 9(cohmnencing with Section l000)of Division 3.f the Business and Professions Code) p A ATION
a Section
ethat 7031. b any applicant
rommdthe permit sujectst deacon p i, , e
W=rn p g p'on. yvioem.n. OUTLETS-SWITCHES-FIXTIIRFS v
�zC Sedinn](IJLS by wry applicum fora permit subject the applicantmacivil penaly.f
TER
ASO a more ohm five hundred dollars P$500)' NEW RFSIUFMIIALGLECfR SO. RIES TYPE CONSTRUCTION
wl o ❑ I,asownerofthcpmpcny.ormyempluymswithwagesutheirwlccompetafi.n,
will m1he work,and the structure intim intendedor offered for sale(Sec.9044,Business
and Profession,Cale:The Contractor's License Law dues not apply to mane,of
property whol uild—rimprovestheeon,and whodocssuch work himself.,through his
employees.prmidedthatuchimpmvementumamimmndedor.fferdfmsale.If. OCC GROUP R13.UNITS
however,the buildingor improvement is sold within one year o(cumpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
`ale')' TY. PLUMBING PERMIT FEE
Las owner oDpa
be prorty, mdQ
ex
usivelycommeting with licensed contractors to FLOOD ZONIi APN
C]
onspoe the p..jecf(Sec.9044,Bmincss and Professions Code:)Tire Contractors
License lawdoes not apply tom owncrofpropeny whobuildsor improvesthemonandPERMIT ISSUANCE
whocomructsfor such projects with acuntractons)licensed pursuant mthe Compactors.AALTER-DRAIN&VENT-WATER EA
License Law. ( ) FEE SUMMARY
❑ 1 am exempt under Sec. .B&PC for this reason Oul SIDI:PIPES
PACK PLOW PROTECT.DEVICE
SANITARY Y N
Owner Date DRAINS-MOOR,ROOF,AREA,COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLI'AX Y N
❑ Thereby affirm that l have a cerificme ofmnsent to elf-insum,or a certificate of FIXTURES-PER TRAP RECEIPT#
Worken'Compensationlnsurnnttoraceniridcopythereof(Sa.380BLab CJwhich PARK FEE Y N
rs tall employee's under chis pennif GAS-EA.SYSTF;M-
RECEIPTN
I INCA OUTLETS BUILDING DIVISION FEES
Company
Policy a
EI Cee CoCAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ ifed copy is hereby famished.
❑ Cmifid copy is filed with the city inspection in.. GREAS171NUU5'1'RI.WAS'TL'INTERCEPTOR GRADING Fl31i
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is hours hurdmddollan(SI00) S ER- ITARY-STORM EA.2(TI ENERGY FEE
or less.)
I certify that in the performance of the work for which this Permit is issued,l shall WATER HEATER W/VENT/ELECTR
not employ any Person in my manner so as tat become subject to the Workers' PAID
Compenmti.mlawsof Califomla. Dae WATER SYSTEMUREATING Date Receipt#
O Z Applicant
Z0 NOTICE 1'0 APPLICANT:ILafcronuing this Cenifict.of Exemptim,you should NEW RESI DENTIAL PLMB. SO,FT. TOTAL:
1'^ ^ become subject t.the Workers Compensation Provisions.(the Labor Code,you must
> foMwith comply with such previsions or this permit shall be deemed invoked. BUILDING ME
GW.. Q CONSTRUCT ION LENDING AGENCY SEI SM IC FEE
Z I hereby affirm that them is a construction lending agency for the perfmmmce of �/ ELECTRIC FEE
U O the work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name PLUMBING FHE
D-' F Lenders Address QTY. MECHANICAL PERMIT FEE
0 U I ccrify that 1 M1avc read this application told stem that the above information is MECHANICAL FEE
coraco. Ingrccmcnmply with all city and c�unty.Ninnnroe and swat laws rtlming to PERMIT ISSUANCE
builiingronamction.andhemby amhorice mpreaenttivesof,iscity tomonup.n the CONSTRUCT ION TAX
U2 abovemmumned employ for truncation purposes. ALTER OR ADD TO MECII.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilitics,judgment,coms and expenses which may in why way accrueagainstsaid City AIR HANDLING UNIT(TO 10.M)CPM)
uexe of the gmntingo Ih'sa // /� /�`
.J AIR HANDLING UNIT(OVER 10.000 CFM)
Sigvmm of ApplialmCommemr Date HXHAUS'f HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,0110 BTU) Date Receipt a
Will the applicant or boom building xc.,an,sire or handle hnrand.us material BEATING UNIT(OVER IOO,1g0 BTU) TOTAL:
as defined by the Cupertino Municipal Code.Chapter 9.12,and the health and Sdmy
Code,Section 25532(a)4 VENTILATION FAN(SINGLE RESID) zic
❑Yes ❑No
ISSUANCE,DATE
6Will the applicant orfutumbuildingoccuprd useagaipmcm ordevices whichemit BOILER-COMP(3HPOR 100.000 BTU)
zmdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(OVER HIIC."BTU)
DumicO n A I D
1C3Yo ❑No NF.W RESIDENTIAL MECII. SQ.<T. Ifs Y1
1 have mad the limardous mmeo.I.,Tequiremems under Chapter 6.95 of the
Califomla Health&Safey Code,Sections 25505.25533 and 25534. 1 understand that ;JUL — a.[
if the building does not currently have a tenant,that it is my responsibility to notify the VIS
Ign
ooccupant t f the requirement which mast he met prior to issuance of a Cenlfcam of
ccupancy. 0117 L. V 11 "I d
Owner or authorired
on, Date TOTAL: ISSUED BY:
OFFICE
PERMIT P-15303
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. Lot No. 9 ^ [�
n A.P.N.: Book 3 2 (-. Page Parcel CC3 Date JU V1 C- a � 1 % -/ 3
Property Owner: PU t1 - 511 I L I Y7
Mailing Address:
(If different)
Telephone: -7 ,JAS 77
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
if G co r7,4-1 a vin r
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family y ; Multiple Family ; No. Units_;1_
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). f
3. To acquire a Plumbing Permit from the of tom" ✓.-A.A O , Building Department and obtain
Inspection and approval by said Building Departmentprior 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):
Y❑�{ 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:
ov
Connection Permit Fee: $ 2
Sewer Service charges to June 30, 191 _,$ 1 /mo.x I mo.: $ 5 ^-
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.
Acknowledgment
Owner's Agent:
(print name)
Receipt of$ 2 acknowledged and permit granted.
MARK THOMAS&CO., INC., District Manager-Engineer
Note:See Details on other side of this permit.
0 0
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as procticoble;
not to exceed five(5t) feet.
w Removable Cleanout Plug
C'
0
a 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
-- FLOW m
Lateral Sewer House Sewer
Lateral Sewer slope House Sewer slope
determined by District determined Dy 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 A
INSTALLATION Jurisdictional Restricuont
Accepted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade Installed Below Grade Instaned Above Grade
Shown Between Street Right-of-Way and Building Srvawn At properly Line Cleanout Shown Adjacent To Building
Requires Regular Mainlenanct Requires Minimum Maintenance Requires Minimum Monlenonce
Valve To Be Removable Valve Should Be Removable
VALVE ACCESS BOX FINISH FLOOR
a u wlVemed Cover
o Level of FIry ISN F100R KELLY VALVE
.N t IKELLY
VALVE ACCESS BO% E
Finish Grade Finish Grotle
Q
F
n Z
BACKWATER "
VALVE
FLOW Al FLOW EY FLOW J?
Notes: e
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.