25128,'m
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY
CITY OF CUPERTINO
APPLICATION/PERMIT
UUMOINO—ELh MVI A.
PLUMBING - MECHANICAL.
PERMIT NO. 25128_
BUILDING DIVISION
BUILDING PROJECT IDKNTIFICATION
BUII.UING ADDR135S:
I
2
DTM
SANITARY NO.
APM.ICA1ONZNNS�SUBMMI/ITUALDATF
I.OTM
RSNAME: PHONE:
C A CfOR'SNAMEE LIC NO:
N/C
CONTROL
Z -
/I Vitt
I S
I I'IECf/IitJGINF.FR: I LIC NO: DRESS:
So ,
D TACI': PHONE:
QTY. ELECTRIC PERMIT
FFF
BUII.DING PERMIT INFO
L PLUMB MECH
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
pPPLIANCL$-RFSIDFMIAL
J09 DESCRIPTION
I herehy affirm that 1 am licensed under provisionsof Chaper9 (commencing with
Section7000)of Division 3ol'Ihe Buainesxand Profession, Cade,und my license is infull
PANELS
effete.
^_
License Class
I License Clusa Lica
UPT010OAMPS
Date Connector
201 - IDWAMPS
111rrr ✓✓✓\/\�
ARCHITECTSDECLARATION
OVER IWO AMPS
SQ. Ff. FLOOR AR
1 understand my plans shall he used as public records.
SIGNS ELECTRICAL
III
i/i I
LicensoA l'rofcseionul
1 OWNER- I3R DECLARATION
esampt License Law for the
1 hereby affirm that I vat exempt from she Cession.
SPECIALCIRCUIT/MISC.
i remon. oli C city., county
slows a.0 Pre,
TEMP. METER OR POLE INST.
which e,pi
I which requiresn permit a a
peoraii 1. common, h, m esu to
aheq impprove, demolish, fi repair nary s[mnure
de
res the
the applicant statement
or to slicensed
PoWIiR DEVICES
j that theat opemtiuofilease La
that hepursuant to the Contractor's License law(Chapter
islicensedth
n Stan.. ion Cod e)
9that exempt
SWIMMING POOL ELLCfRIC
VALUA'T'ION
he is therefrom and basisioaphelleexemption. Any
s pp'on, yOUTLETS
Secle heisex la may.plmmand the basic for Ne allegedexem u Anviolationot
Section M1y any applicant fora permit subjecu the appliam m a civil penalty of
- SWITCHES - FIXTIIRE.S
/� p
W
_`Jg
not morethan
than dollars HISOOO.
rvehundred
� ❑ I, ueowneroftheproperty,ormyemploycee withwegeruatheirsolecompensmion,
NE RPSIDHNTIAI. FILE _SQ.F
STORIES TYI'13CONSTRUCTION
will dathe wons and sh coure eal
I Z
,
and Code: Contractor's Loom , Lm,
Code: The Conthemons Lkene law does not apply ff an owner of
deco notapply to an owner of
property
progeny who builds vi improves
wh bu and who does such work himself onhrough his
OCC. GROUP
RES. UNI'T'S
t suchmeon,
ownhowever,[hebuildigoraned atsementirovementhinne ernded Rred firthe
however, the building is said within one year or inumpl theowner -
urimpmvemein
builder omm efor
improve
builder will have the burden of proving the he did not buil) or improve for purpose of
pose of
( L'
'Oh.).
❑ I, as ownttof the progeny,emexdosivelycommnmg with liansedcontrannmm
QTY. PLUMBING PERMIT
FEE
PLOOD ZONIi
qPN
.nuts, the project (Sec. 7044, Businessand Profession Cade:) The Cotnmcers
License Law does not.upply torn ownernfpfopeny whobuildsorimproves thereon, and
PERMIT ISSUANCE
whocomnans farsueh murals with. corharma,i) licensed pursuanuothe Crairomose.
License law.
pLl'ER-DRAIN&VENT-WATER (FA)
FEESUMMARY
❑ 1 am exempt under Sec. , B & P C for this mason
OUTSIDE MPS_
BACK FLOW PROTECT. DEVICE
SANITARY YN
RECFIPI'q
Owner Dau
WORKMAN COMPENSATION DECLARATION
DRAINS - FLOORROOF, AREA, GOND'
, .
SCHOOLTAX Y N
`❑ I hereby affirm that l have acetifcae ofconeatto self-insure,orn cenifica[e of
FIXTURES - PER TRAP'
RF.C131PfM
PARK FEE YN
.,kalif Compensation Ins umnceorocenified copy thereof(Sec.3gIXl, Lab C.) which
covers W employee's under this pertain.
GAS- -1 INC.4OUTLETS
RRC131Pfp
RLWADIVISION FEES
PLANCHE ��
.SY
PolicyM
Company AS.E ' .OVI 3A)
❑ Cenified copy is hereby furnished.
❑ Cenifiedeopy is Bled with the city impectlon division.
ND S L RCEPI'OR
GRADING
CERTIFICATI. OF EXEMPTION FROM WORKFRS'
R GTRA
SOLI. E13 l�
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is foronehundrzddollvs (EI
SE A ANITARY-STORM IA. 300FT.
F11,RGY :E
or e.)
I camfyflat inthe performance of the work far which this pe.it is issued, l shall WATER HEATER W/VENTJMECI'R
not employ any person in any manner so ase become subject to the Workers'
PAID
Compenvtion Lawsof Califamia. Date
WATER SYSTEM/IREATINGDae
g
Applicant
NOTICETO APPLICANT: ILifurmakinithis Certificate of Exemption,you should
NEW RESIDI?NTIAL PLMB. SQ. FT.
TOTAL:
become subject m the Worker's Compensation provision of the Labor Cede, you must
BUILDING FL'L'� Z,] _
fnnhwlth comply with such prnvislone or Otls permit shall be deemed revoked.
SEISMIC PI3E ;�?sQO
CONSTRUCTION LENDING AGENCY
1 hereby affirm Phot he. in vcon.... enon lending agency forthe perfomance of
ELECTRIC FRE
the work for which ilia pemilt is issued(See. 307, Civ. C.)
Lenders Name
Lender's Address
QTY. MECHANICAL PERMIT-
FEE
PLUMBINGFEE \ 1
I certify that 1 h.vo rood this application and amore that the above iarrnmannn is
MECHANICAL. FEL?
correct. I agree m comply with all tiny and county ordinances and state laws relating to PERM IT ISSUANCE
buildingconswction, and hereby auJmriu repms ntwives of this dtym enterupon the
property pection
ubov(Wa)agredfor ins putpo
ALTFiR OR ADD TO MI3C11.
CONSTRUCTION TAX
(We) agree m save, indemnify and keep ino.harmless the City of Cupertino id Cit t
cast andexpenxs which they in anyweyaccrue against said City
AIR HANDLING UNI'1'(TO lo,gk)CFM)
3 6 37
incomcs,juJgmems,
inconscyue ee afdie grvning of this permit.
AIR HANDLING UNIT (OVER 00,000 CPM)
S" natumof Applicam/Con us,r Date MiAUSTHOOD(W/DUCq
PAID
IIAZAR S D .
ATERIALSOSURG
HEATING UNI'I'(TO 100,(k10 BTU)
Data Receiptp
Will the applicant.,future building occupam s,am or handle hmnrdous matenal
as defined by the Cupertino Municipal Code, Chapter 9. 12, and the Ileahh and Safety
HEATING UNIT (OVER IW,tKKI BTU)
Code, Section 2553200?
❑ Yes CI No
VCNTILATI(N 'AN (SINGLE RI SID)
SUN F ATE
BOILER. COMP(3HP OR 100,000 BTU)
building equip
Will tai,
? / /
���CCC �1f5e C
conicamo ms; as by the
uzerdous air conteminan[s as defined by the Buy Arca Air Qualify Management
Air Quality Mange ant
BOILER-COMP(OVER 100,000 BTU)
a
❑ Yes ❑ No
NEW RESIDENTIAL MECH. SQ. FT.
MAR - 1 1994
1x�
I have read the humidities materials requirements under Chapter 6.95 of the
•
California Health & Safety Cale, Sections 25505, 25533 and 25534. I understand din
if the building does not currently have u tenant, that it is my responsibility to notify the
COY
d (,/f C;Lkienl BOIU
occupant of Na requirements which must be met prior m issuance of a Certificate icate of
Occupancy. .. .
_.
Owner or authorized agent Date
ISSUED
urr-lure
�, -'amu—f-,.—,.� ,..�-�,c a=.....,,,� m� � a� iv ri,.r, y., .. r:,. - � .•.�.,,.. _.::
. yaR"T'd tV'
k PERMIT P--15334
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. 19352- Lot No. Z
A.P.N.: Book] Page /0 Parcel 6
Property Owner: 6/)4UY6,y h%fid o/JPi-i APs
Mailing Address: 2 y 4'L/ 0 CG "I b0yV G`'f
(If different) t�e e- �f Mo
Telephone: 2 S S— 32 L 3
Date /i /9 %y
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
2Ii21 /24t1obee-y -Drl\/C.
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family_A ; 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 , Building Department and obtain
inspection and approval by said Building Department prior to covering df 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. N
FEES:
aC�
Connection Permit Fee: $ 76, —
Sewer Service charges to June 30, 191�L , (0 sr" /mo. x Amo.: $0!!�
Inspection Fee for backflow protection device: $
t
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.
Acknowledgments-- "�/ . �.
Owner's Agent:
(print name)
obi
Receipt of $ 7G acknowledged and permit granted.
MARK THOMAS & CO., INC., District Manager -Engineer
Note: See Details on other side of this permit.
J
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
a, not to exceed five (5) feet.
c
iD
T
w Removable Cleanout Plug
n
a. Finish Grade
Wye for Riser L�111iser
Sewer Cleanout Box with Lid to be accessible
and maintained by property owner.
Short length Pipe
Bend
Adaptor coupling �FLDW m
Later r House SrevNerLaferal Sewer elope Houe Sewer sloDe
determined by District detmined 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
Jurisdictional
Restrictions
Accepted By All Jurisdictions
FIGURE I
FIGURE 2
FIGURE 3
Installed Bala. Grade
Installed Belo. Grade
Instatled Above Grade
Shown Bet.un Street Rlghl-ot-Way and Building
Shawn At Properly tine Cleanout
Shawn Adjacent To Building
Requires Regular Maintenance
u Requires Minimum Maintenance
Requires Minimum Maintenance
— Valve To Be Removable
Valve should Be Removable
VALVE ACCESS BOX
FINISH FLOOR
.Ithy Vented Canr
o
OOR
c v l FI l H Fl"
VALVE
VALVE ACCESS BoxE
a. a
m
'�'jj�d )1'.
Finish Grade �L
Finish Grade
MKELLY
1
In,
BACKWATER
VALVE
FLOW DJ
FLOW 3f'
� FLOW P/
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
e