26119 i
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - '-.ECTETCA. PERMIT'NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL 26119 aI 'I (J
BUILDING DIVISION BUILDING PROJECT IDEN'L'IFICATION 6 1 1 J
BUILDING ADDRESS
: ///J / Jct �f/ SANITARY NO. APPLICATIONSURMDTALDATE
22 Jbo / `; `—+l rdo tCa ' UNIT LOT#
.Y`OWNERS AME.:., PII NE:
CON' CfOR'S NAME: LIC NO: N/C CONTROL.
Un erI P (qv Weer- T/2 1�/ C�o,A/1 C��(of }
ARC111TECT/ENGINEER: LIC NO: ADDRESS:lr hC CA r — C� [ ``IG J
A CONTACT': PHONE: '4A�* h4NN $R�2"'RS d,�n4fn - a +fr
�-
Q'fYd. ` , ELECTRIC PP.RMITT', "'•eI'EE •a BUILDING PERMIT INFO
'#f 3trr&ef#3s�t#'-''J' BLDG ELECT PLUMB - MI:CII
PERMIT ISSUANCE ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
QWz Ihereby cM.chat l am licensedinderprovision..Mhspmr9(.nobeingwilt
�00 Scene.9W).f Division 3o17the Businessand Professions Code,and my license is in PANELS ♦ .� ,//�
16,5 full force and effect `r',Z U �J gel J J�
racyUcrds C s Come-on / r� , UP TO 200 AMPS �M/�/V��I/A
are201-IOW AMPS
z0oe Zr ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA HSQ.FT.
O Z"1O 1 understand my plans shall he used as public records.
F^ W SIGNS ELECDHCAL
Q�d Licensed Professional
OWNER-BUILDER rDECLARATION SPECIAL CIRCUIT/MISC.
OyF I hereby reason,Se that I am exempt Froin the GO�tend sions o License Law for the
follow6J✓r-m which og requirsafrnta,ction 9031.5.t,alte,improve,drims Code:Any can mmeturn county TEMP.METER OR POLE INST.
which rc9niesr ,.Immconstrue,sliceimprov,,h permit to
mrepair any iderourc -
}� dedhe its tensed ,alsorequircstheapplicantfo cContr cteto License
La sta.menr POWER DEVICES
p�j p O doer he is licensed Pumuanno the provisions of the Conwaors Littnx Lew(Chapter
9(enantereng with Section 7")mfDivision3nfthe Business and Profusions Code) SWIMMING POOL ELECTRIC VALUATION V
W_m or that he is exemptaherefrom and the basis for alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURPS
tKQ S«tion]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars($500).
W m ❑ 1,asowterofthepmo ny.ormyempinmswithwagnmtheirsolecompensation, NEW RJESIDENI'll ELECfR _SQ.FT. STORIES TYPE CONSTRUCTION
p will du the work.and the swcture is not irneWedoroffered forsale(Sm.]044,Business V
and protections Cade:The Convector's License Law does not apply to an owner of #
property whobuildsorimprovesmemon,and whadoesmch work himselfortheoughhis
oaneniployces,provided that such intpwvememsnrenot imendedoro(fend forsale.If. OCG GROUP RES.UNITS
h waver,the building or improvement b bold within one year ofsompletion,theowner.
on Ider will have the hoolen of proving thin lie did not mild or improve for purpose of p
an❑le)1,wownerof th,Propeny,am exclusively sacro with licensed contractor,t QrY�y3hI PLUMBING PERMIT: i-EEt " FLOODZONI? nl'ry
answer the pmje-(Sec.7044,Business uad Professions"'o.'The Conmmtor'e
License Low does not applyto,.own,rofprnpeny whohuilds on improves thereon.and PERMIT ISSUANCE
who contracts forsuch pmjecta with a contracwr(s)licensed pursuant to the Conlmemr's AL'T'ER-DRAIN&VENT-WATER PA PF-E SUMMARY
License law. ( )
❑ 1 am exempt under Sec. ,B&P C for this mason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owntt Dam DRAINS-FLOOR,ROOF,AREA.COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
�❑ I hereby offum that l have acenifiam ofconsent to self-insure,or a cenifcate of FIXTURES-PER TRAP RECEIPT#
Workers Compensation brurnmee r a certified copy themof(Sec.3800,Lab C.)which PARK FET: Y N
,.vera all cmploya's under this peril. GAS-HA.SYSTEM-I INC.4 OUl'LETS RECEIPTN
Policy# BUILDING DIVISION PEES
'Ae°nY GAS-HA.SYSTEM-OVER 4(EA) PLANCI IFCK FEE
C-tified copy is hereby famished.
❑Nortificil copy is filed with the city inspection division. GREASE9NDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF.ASETRAP SOILS PER
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars(SIM) SEWER-SANITARY-STORM P.A.200FI'. ENERGY FEE
or less.)
I cenifythm in Ne perfa ce of the work for which this permit is ismed.l shall WATER HEATER W/VENTIELECIR
.at employ my person in any mainer so m to become subject to the We&.' PAID
z Compenmtionlawsof Califomia. Dam WATER SYSTEMGREATING Date Receipt#
Applicant
H0— NO'TICETO APPLICANT:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT, TOTAL:
CG becomesubjectto the Workers Compensation provisions of the Labor Code,you must
� > forthwith comply with such provisions or this permit shall he deemed revoked. BUILDING FEE
Lkl Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued(Sm.3097,Civ.C.) TOTAL: ELECTRIC FEE
I<ndcrs Namc PLUMBING FBI?
u-' F"
her Addmss QTY. '�, :MECHANICAL PERMIT " PEE-
D U E cendy that 1 have read this application and state that the above information is ° "-#d '-'
0. core-.Iagree wcomply withall city and county ordinance rdince andminings,..laws mining to PERMIT ISSUANCE MECHANICAL FEE r
_ '4buildingranruction,and hereby authorize rep.umativee ofthis city wenterupon the
U z Slave-mentioned property for inspection purposes. ALTS-RORADDTOMECH. CONSTRUCDONTAX
(We)agree w save,indemnify and kap hmmless the City of Cupertino against
.. liabifiies,judgmenu,costs and expenses which may in my way mems ag.nsts'd City AIR HANDLING UNIT(TO 10,OOIICFM)
moJ�ose/�n.,e/yr �f the grun�t�:./epf this t.
A��"/�1'✓A'1 /�C. 3�a f, AIR HANDLING UNIT(OVER 10,000 CFM)
Signu�nVContracmr Dar HXHAUSTHOOD(WMUCT)
PAID
HAZARDOUSMA'1'ERIALS DISCLOSURE HEATING UNIT(TO 100,00011TH) Date Receipt#
Will the applicant or future building occapunt entre in handle hazardous material
as derined by the Cupertino Municipal Code,Chupmr 9.12,radio,Health end Safety HEATING UNIT(OVER 100,000 BTU) T
Code.Section 25532DY VENTILATION PAN(SINGLE RESID)
13 Year ❑No
BOII.F.R-COMP(3HP OR 100,000 Bill) ISSUANCE DATE
Will the aexamom mfuas building occupant use equip Air Quality Mwhich emit P
.M1 mous air cnntmninan¢m defined by the BeY Area Air Quality Mmmgenrcm BOILER-COMP(OVER 100,(1(10 BTU) A D
Dow-T
1:3 Yes 0N NE?W RESIDENTIALMECIL SQ.IT. NAh
1 have read the hazardous materials requirements under Chapter 6.95 of the I►(H 9 �(I^�
Odifnmin Health&Safety Code,Sections25505,25533 and 25534. I understand that Cf�y w Aa�
ifthe auildingdocsnmments which
ustlm et Prirmy res
uance bfa Cernmifythe V u(\`�
muPaul nl'the roqulmmems which must la mm prior m issuance of a Certificate of (�
Occupancy. V /
Owner or mahmired agent Dete TOTAL: ISSUED BY:
— f
.r.��-K+.--.y..r... rv,.0 -:wav,..,.o+w•-w.rf;n..4..�Y 'ri++r,M..y,. f,... ,.. ., .f ...wnas..e,C,r.. .�.-r. .,,...n..e.. r r f R^J'�f—,.�S...r.y..�1.,eq\x... y .o q-..�.t. ..
,�- PERMIT P-15336
" CUPERTINO SANITARY DISTRICT",
Santa Clara County
20065 Stevens Creek Blvd., Bldg C, Fax (408) 253-5173
Cupertino, California 95014
i t{
Phone (408) 253-7071 r
CONNECTION PERMIT
R.O.S./P.M./Tract No. Lot No.
A.P.N.: BookS-1-6PageParcel OC Data
Property Owner: Va ler rP !v . )eel 4�0
Mailing Address: .56 P2//r mer UJ et
(if different) 4 O S A��ns , ex 9,40 2 Z
�rTelephone:
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
v2 5-6
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family Y_; 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 G of CQKtZA �b Building Department and obtain
inspection and approval by said Building Departmerit 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. 1
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.
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:
Connection Permit Fee: f $
Sewer Service charges to June 30, 19��,,,4
�,$ 1603D /mo.x I mo.: $ �o
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 ,r
Acknowledgment: V
Owner's Agent: r
(print name)'
Receipt of$ ��13 acknowledged and permit granted.
•y MARK TtPMAS& CO., INC., District Manager-Engineer
b
Note:See Details on other side of this permit.
TYPICAL CLEANOUT FOR LATERAL SEWER A
Distance from Property Line
to be as close as practicable,
not to exceed five(5) feet.
c
J
T
I Removable Cleanout Plug
la
0
li Finish Grade
Wye for Riser
Sewer Cleanout Boz with Lid to be accessihle �
and maintained by property owner.
Short length Riser Pipe
/B Bend
Adaptor iDitrict
LateraHouse SewerLateral SeweHouse Sewer slope
determined bdetermined by building department
— CLEANOUT TO BE SAME SIZE AS LATERAL SEWER—
Notes:
1. Distance from the property line not to exceed five (5')feet.
e 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
ACceaHit By All Juriedictione
FIGURE I FIGURE 2 FIGURE 3 1
I,nrolled Below Grade Installed Below Grade heated Above Grade
shown Between street Rleht-obWq and Buildlnp Shown At Pr.lorly line Cleaneul Shown Adlocenl To Building
Requires Regula Maintenancei Requires Minimum Maintenance Re Wires Minimum Malnlenanae
Valve To Be Removable Valve Should Be Removable
v- VALVE ACCESS BOX
a with/Veered Cover FINISH FLOOR
i
Laval of FINISH FLOOR KELLY VALVE
AtKELLY
VALVE ACCESSBOX EFlnieh GradeFlnieh Grade Z
to
BACKWATER
VALVE
i FLOW 6T FLOW FLOW Dl
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.
L