25580 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B171LUT .-F.LF.c I RICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PING,PROG-MFIDENTIFIC 2 5 5 8 0
IIUILMNG PR(IdRCI'IDEN'TIPICATION
BUILDING AMRIESS: T SANITARY NO. APPLICATIONSUBMITTAL DATE
/��
( 1 C)I 1w l[�03� e 4 . UNIT# LO s �y
OW E SHAME: ) PHONE: CO L/�pR'S LIC NO: N/C_T CONTROL
G / G
R IgEC/'/[i�'GI LIC NO: ADDRI-MM((SF. ❑
orrfAV: PH N BUILDING PERMIT INFO
2.o/�ppe T'Y. ELECTRIC PERMIT FEE
b BLDG ELECT PLUMB MECII
( PERMIT ISSUANCE ❑ ED El
LICENSIID CONTRACTORvismos ARATION APPLIANCES-RESIDENTIAL
pyy Iherchy affirm CENSE liCONTuACTORvisDECLf RATI 9(commencing with
tr]00 Section] f Division 3 of the Business and Prafeesione Code,and my license is in PANELS
yF' full fa onde
ec UP TO 2(MIAMPg
FZw Licen eeClma Lic.
--7 y Data cmr 281-1"AMPS S FT.FLOOR AREA g/SQ.f?.
OZ�y DECLARATION OVER IBRO AMPS Q'
1 Jerst Ala public emembi
SIGNS ELECTRICAL r (g �
fp \�R
Ec)�u cert rte a OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. h I•� A L E ^
S�eeOaF I hereby tint Nn 1 am exempt from she ConionsCe License Low for the ■
u13 is.w fallowing hereby
a(Section hat I.e Business and he C a act Code: ens ei Law
county TEMP.METER OR POLE INST. /
0 Ja which oquirea a permit to construct.alta,improve,demolish,or repair any structure
;!(>.� priorto its issuance,also requires the applicant for such Permit to File a signed statement POWER DEVICES
1„�C p thin he is licensed pursuant m the provisions mthe Convector's Licence Law(Chapter
d0.o�' 9(comerencingwith Semion 7000)of Division3ofthe Business end Pofessions Code) SWIMMING POOL ELECTRIC
W ern or that he is exempt herefrom and the basis for the alleged exemption.Any violation of OIITLBTS-SWITCHPS-FIXTURES
4 Section 7031..So any uppI.not for a pannit subjects thesuphcaut m a civil penalty of
p tmmre than fivehundresldollam(5500).
m n❑ l,asownerofthepmparty,ormyemployeeswithwagesmtheirsolec=Natation, NEW RESIDENTIAL ELP.CTR -SQ.PT. STORIES TYPECONSTRUCI'ION
willdo the work,and thestructute is not mandmoroffered forssle(Sm.70,14.Business
and Paressmas Code:The Contractors License law does oat apply m on owner of
property whobuildsor improves theremand whodoessuch work hinerelfunhrough his OCC.GROUP RES.UNITS
own employees,provided thatauch i mprovemenu are not intended or of fcmd for sale.If,
however,the building or improvement is sold within one yearmfcmmpletimn,the owner- TOTAL:
builder will he.the burden of loving that he did not build ser improve for purpose of
e.).
❑ Las ownerofthepnn
ropy,am exclusivelymnvacting with licensed contractors toQTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct the project(Sec.7044.Business ental Professions Code:)The Contractors
License law deene
enot epplytonnowrofproperry whobuildsm improveatherton,mul PERMIT ISSUANCE
who contracts for such Pojrets with a mortmctorEd licensed pursuant to de Conoacmrs ALTER-DRAIN&VENT-WATER(8A)
License law. FEE SUMMARY
❑ I am exempt under Sm .B&P C for Nis rcasmn BACK FLOW PROTECT.DEVICP. IITSI '
SANITARY Y
Owner Dote DRAINS-MOOR.ROOF,AREA.COND. RECEIPTp
WORKMAN COMPENSATION DECLARATION SCHOOLTAX YN
❑ I hereby affirm that l have o ceniftcate ofconsent mself-insurc,oracenificmemf FIXTURES-PER TRAP RECEIPT#
W°rkers'Compensmion hautnneeoruernified copy thromf(See.3800,Lab C.)which PARK FEE Y N
re s11 employee's under this permit GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSI'RL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(This section need not he completed ifthe permit is forms,hundred dmllars(SI00) SEWER-SANITARY-STORM EA.2WFT. ENERGY FEE
or less.)
I camifythat in the perfmmanceofthe work for which this permit is issued,I shell WATER HEATER W/VENT/ELECTR
not employ any person in any maturer so a m become subject to the Workers' PAID
Cmmpenationlawsof Celifomia. Data WATER SYSTElilf BEATING Date Rmcita#
� Z Applicant
C) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(A become subject °the Workers Compensation provisions of the labor Code,you must
fmnovith comply with such provisions or this permit shot[Ire deemed rev°ked. BUILDING FEE
W A CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that there is u construction lending money for the performance of
U the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC IPE
Isndc's Nume
F' Lendar'a Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U I certify that 1 have read this application and sate that the above information is
�" a correct.[agree to comply with all city and county ordinances and sure laws relating to PERMIT ISSUANCE. MECHANICAL FEE
building constructioW
prcaenutives ofthis city tcenterup°n the CONSTRUCTIONTAX
U z shove-mentioned
form
pmea. ALTER OR ADO TO MECII.
(We)egrce t say
p esa the City of Cupertino against
gme mayinanywey ace eegain snit City AIR HANDLING UNIT(TO 10,00)CFM)
ceo AIR HANDLING UNIT(OVER I OdOW CFM)
Signut App1' UC trecmrG Data HOOD(W/DUCq PAID
RDOUS MATERIALS DISCLOSURE HEATING UNIT(M 100,000 BTU) Data Receipt
Will the applicant or future building occupant store in handle hamrdous material
as defined by theCup,nino Municipal Cade,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1011,00X)BTU) L
Cob,,Section 25532(a)'I
❑Yes ❑No VENTILATION PAN(SINGLE RfSID)
ISSUANCE DATE
Will the applicant or future buildingoccupantuseeuip
qmenwrdevicee whichemit o
BOILER-COMP CHP OR Ifl0de BTU)
hamrdoux air ma um mods ex defined by the Bay ARB Air Quality Management BOILER COMP(OVER IDLD00 BTU)
District? Y
❑Yea ❑No NEW RESIDENTIAL MECH.-SQ.FT.
I have read the hamrdous materials requirements under Chapter 6.95 of the If s
California Health&Safety Code,Sections 25505,25533 and 25534.1 undmundthat 19
Wife n In the building does not currently have a Preethat it is my responsibility notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
Occupancy.
Owntt or authorised agent Date TOTAL: ISSUED BY:
OFFICE
,
PERMIT P-15'311
CUPERTINO SANITARY DISTRICT '
$ants 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. 1 IS-70 Lot No.
A.P.N.: Book 32 Page /,/' Parcel AB'-G7 7 Date � 1� /� em L e,,' 2, 1'9 9-3
Property Owner: J / r i kue-e y-G.-.
Mailing Address: 2 19 O J M o Ole Gfi
(If different)
Telephone: �57 9lo I
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
2 / 9a / 440n4(f e 1e", te
�or.41v» 0
consisting of the following TYPE OF BUILDING(S):
Residential`. Single Family�; Multiple Family ; No. Units____t_
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 6&!4of 6J Building Department and obtain
inspection and approval by said Building Department rior 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 constructio �-the House Sewer.
5. That this permit does not constitute l uest for the issuance of an encroachment permit for sewer constrin 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(Exhlbi• �t
� I
❑ 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: $ 76
Sewer Service charges to June 30, 1994 ,$--16 SO/mo. x/0 mo.: $ 16 s=ue
Inspection Fee for backflow protection device: $
CP ,
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.
.r
Acknowledgment
Owner's Agent:
(print name)
Receipt of$ acknowledged and permit granted.
MARK THOM S&CO.,INC., District Manager-Engineer
by.
Note:See Details on other side of this permit.