25265 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPESIONkxuuluu - C PERMIT r+o.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGCTIIDENTICAL
FIC
BUILDING 1'R(9JECI'119EN'1'IPICA'1'IfIN
BUILDING AA DBMS: C ,�./•g /. • ' /�� SANITARY NO. APPLICATION SUBMITTAL DATE.
�1 9 `e+ - YY �f +� UNIT# LOT It
OW F. MORo� PHONE: CONTRACTOR'S NAME: LIC NO:It a. N/C CONTROL
as
r'
RCI 'C'I' N IN s LIC NO: RESS:
r El
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEB BUILDING PERMIT INFO
BLDG ELECT PLUMB MIiCH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL 108 DFSCRI N
thereby affirm that lam licensed under pno isiotoofChapter9(commencing with
Seclton7fbabof Division 3ofl1e Businesssnd f,so d�yli venin PANELS
faily
License
nse Class
cffccs. -6� 5 UP T0200AMPS
License Class Lic,p VVV
co y DateConvactor 201-11100 AMPS SQ.PL.FLOOR AREA t/SQ.FT.
Fye ARCHI SDECLARATION
oz— 1 tun plus madaspublicrxords. OVER 1000AMP5
F L SIGNS ELECTRICAL
rffL'en lesional
y u1 OWNER.BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
yxx OgwF I hereby affirro that I am exempt from the Contractor's License Law for the
W'3 pw following myon.(Section 7031.5,Business and Professions Code:Any city or county TEMP.METER OR POLE MST.
kJ rn which requires a permit to construct,ether,improve,demolish,or repair any avucture
E }� prioro in issumrea tce,alsorequitheapplicent fmwch Permit o file.signedsutemem POWER DEVICES
cep
that he is licensed pursumt lm the provisiom.fthn Contractors License Law(Chapter
Ly�do�' 9(wnammeing with Section 7000).(Division 3.fth.fbiabessn.d Prefenuma Cede) SWIMMING POOL ELECTRIC VALUATION
Wim or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
GSection 7031.5 by any applicant for a permit subjects the applicant w e civil penalty of
not mom than five hundred dollars(1500).
� � ❑ I,v.sorter.(thepropmy.ormyemptoyecawithwagesvlhcirwlecompenuuon, NEW RESIDENTIAL ELECIR FT.
S Q' STORIES TYPE CONSTRUCTION
a willdo the work,motion svucmmisma ilnendedoroffend forule(Sm.7W,Business
and Professions Code:The Contractors License Law does not apply to an owner of
property whobuildsor improves thereon,and who does such work himselfortluoughhle OCC,GROUP RBS. ITS
own employees,provided thmre
xuchimprovements anatimmndedoroffered forule.If,
however.the buildingor improvement is sold withinoneyearofeempletion,the owner. TOTAL:
builder will have the bade.of proving that he did not build or improve for purposeof
❑ I,as nwnerofthepropeny.ant exclusively convening with licensedconv.ctmeto QTY. PLUMBING PERMIT FEE Fl,OOn LONE APN
construct the project(Sec.71194.Business and Professions Code:)The Convector' a -
LicenseLawdmwtapplytowownerofpmNnywhobuildsorimprovesthereon,en 1 RMI SS AN
who contractsfarsuch projects with econwetor(s)licensed pursuuu...—o.Z'ar�a ALTER-DRAThI -�P ATIi
License Law. FEE SUMMARY
❑ I em exempt under Sec. ,R&P C for this meso I VI
-� SANITARY Y_N
Owner Dem RECEIPT#
WORKMAN COMPENSATION DECLARATION AINS- ,R SCHOOL TAX YN
❑ Iherchy affirm that have ettnificam of consenno selLinmrc,arattni me of -QAFl RECEIPT#
Workeri Compenutianlvurancemaecnified copy Nereof(Sa.JB00,lab C. hlch PARK FEE YN
coven all employer's under this permit. PAS-EA.SYSTEM-1 INC.4 OUTLETSRECEIPT#
Policy p BUILDING DIVISION FEES
Company OAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
Certified copy is hereby furnished,
nifed copy is filed with the city inspection division. GREASRJNDUSTRL WASTE.INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRP AP SOILS FEE
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is fsrone hundred dollars($100) S WER- ANITARY-STORM EA.20 g�Eerr IesaJI certify that in the performance ofthe work for which this permit is issued,Ishadl WATER HEATER W/VENT/ELECTR
nm employ any Panama in any reavm w u to become subject w the Wmimni'CompenutionlawsafCalifomda. Due WATER SYSTENVIAEATING Receipt#z Applicantz2NOTICE'W)APPLICANT:If,after making this Cenifcamaf Exemption,you should NEW RESIDENTIAL.PLMB. SQ.FT. TOTAL:(4become subject to the Workers Compensation Provisions ofthe labor Code,you must, forthwith comply with such Provisions or this permit shall be deemed revoked.OCONSTRUCTION LENDING AGENCY
I hereby affirm Nat them I..r...burden lending agency for the parlt mwce of IiLECIRIC Fill,
work for which this permit is issued(Sec.307,Civ.CJ
0 Lendera Name PLUMBING ME !`
O t<ndI e Add.. QTY.. MECHANICAL PERMIT NEE
1.I t 1 have read this ity sold don and smhe Nu the above information relang is
}' 0. building ree amply I city sold coumymdtnwttsand atom lewxreladngto PERMIT ISSUANCE MECHANICAL FEE
above- nsvuc on, herb set mizempmunmdvee oflhie city toemerupnn the CONSMUC 1ONTAX
(� iFj7 above- )all a pro o,iml con pcepnsea. ALTER OR ADD TO MECH.
( e)erg 10 so,inJ if w cep hunnlcse the City of Cupertino against
nco
tY e,ju ton ,ensu c yway eccrueegeinst aid Ciry AIR HANDLING UNIT(TO UL"CFM)
in
n con uof a thi
AIR HANDLING UNIT(OVER I0.000CFM)
.igna MApp cant/C.mrucmr Dem EXHAUST HOOD(W/DUCI) PAID
HAZARDOUS MATERIALS DISCLOSURE. HEATING UNIT(TO 100.000 BTU) Data Receipt#
ill the app¢ant or future building occupant atom or handlehvardous material HEATING UNIT(OVER IW,o00 RTU) TOTAL:
fined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
Code,Section 25332(e)7
11Yes ❑Na VENTILATION FAN(SINGLE RMID)
❑
Will theupplicwtorfmurt buildingoccupwt uxequipnhemardeviaswM1icM1emit
BOILER-COMP(JET OR 100,000 BTU) ISSUANCE D
Ianrdous air contaminants u defined by the Bay Area Air Quality Management BOILER-COMP(OVER 100,000 BTU)
islrin7
❑Yes ❑No NEW RESIDENTIAI.MECH. SQ.FT.
I have read the hazardous ma rials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25573 and 25534.1 undenalamd Net
if she building does not currently have a mnarn,that it is my responsibility w notify the
occupant of the requirements which must be met Prior to issuance of a Cenificate of
Occupancy. ~
Owner or authn fired agent Data TOTAL: ISSUED BY:
PERMIT
l CUPERTINO SANITARY DISTRICT
Santa Clara County
20065 Stevens Creek Blvd., Bldg C, Fax (408)253-5173
Cupertino,California 95014
Phone (408) 253-7071
CONN// ^^ECTION,PERMIT
• R.O.S./P.M./Tract No. ( Lot No. 4
A.P.N.: Book Page _Parcel 07 2' Date JU✓1 e /6 , / 9 ,93
Property Owner: Roloerl k .
Mailing Address: 2 1 10& M A I C ct
(If different) 6-� le& 4AA,0
Telephone: 2'S S q?✓
1
Sirs: '
(I/We), being the owner(s) (owner's agent), hereby make applicatiyn for connection of the property at:
2 iq0� e CA , at� �wv
consisting of the following TYPE OF BUILDING( ):
Residential: Single Family \ 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 (::;J AA vs,t 0 Building Department and obtain
inspection and approval by said Building Department Orior to covering of fhe 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:
pCr
Connection Permit Fee: $ 2 �?
• Sewer Service charges to June 30, 19e)2-0 ,$ 1 S� /MO. x mo.: $ J�
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:
41,
Owner's Agent:
(print name)
a�
Receipt of$ � / acknowledged and permit granted.
MARK THOM S&CO., INC., District anager-Engineer
b .
• Note:See Details on other side of this permit.
TYPICAL CLEANOUT FOR LATERAL SEWER Io
Distance from Property Line •
to be as close as practicable,
a, not to exceed five(5) feet.
c
J
T
m Removable Cleanout Plug
a
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 /8 Bend
Lateral Sewer House Sewer
Lateral Sewer slope House Sewer slope
determined by District arldetermined 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 Jorisalo]ianol Rutrlction. •
Accepted By All Jurisdiction.
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade InstalMd Below Grad• Installed Ago,. Grade
Shown Bsnreen Street Righl-a/-Way and Building Shown At properly Line Cl.....I shown Aduc.nt To Building
Require. Regular Maintenance W Requires Minimum MchlimcmC. Requires Minimum Maintenance
V.N.To Be Removaal• Valve Should Be Removable •
F VALVE ACCESS BOX
FINISH FLOOR
a wlth/VentedCover
w
ii Level FlNI KELLY VALVE
0
` mien Grad*
N�
VALVE ACCESS BOX KELLY VALVE
Finish Grade —�
Finish Grad.
F �•
m 3
n
BACKWATER
VALVE
1 FLOW FLOW Ar
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. 11 a Kelly Valve is installed at Property Line, it is to be readily removable for Lateral Sewer Maintenance.