22525 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
pildingpAddms: 22525
arse:
one: SUBMITTAL
neva — CITY OF CUPERTINOLBUILDINGDIVISION
ConbactpYs Name: Lie.No: APPLICATION I PERMIT
BUILDING ELECTRICALPLUMBINGMECF LAICAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby n7OOOatlamlMen3oftheunder
urineprovisions at Cssions 9(mmmmn APPLIANCESRESIDENTIAL JOB DFSRBrI'ION
IngwefisinioUlorecandelect. !the Bueinessand Pro(osionsCodc,and my S��
License Is in s force and eIt.# PANELS
License Ch® Cont
Date Comnctpr UP TO 2DOAMRS
ARCHITECT'S DECLARATION XII-IOW AMPS
p�
�Z Iundentand myplausshallbeused as pub@records. OVERIOOOAMPS SQ.IT.FLOOR AREA $/SQ.FT.CO
L' (s Licensed Profemional SIGNS ELECTRICAL
G a OWNER-BUILDER DECLARATION T E D E N
Z Y SPFCIALCIRCUIT/MISC I V J /1
Ihmeb alfirmthatlam exam from Contractor's License law for the /!-0
pp t following rescan.(Section 20315,Busmen a lte ro/pmve Code:Any my or C-Oqu psi
O 2" TEMP.METER OR POLE INST. N
Fy countywhich requlmapemNtro.nstrvn,ilter,bnprove,demoWh,prrepilr
ale
mpHortolb Wuance,ilsorequimtheappUmnt(msuapermitto POWER DEVICES
r ale a signed statement that he V Bcensed pursuant to the provisions of the
3w C mranoYs License Law(Chapter 9(commoncingwlthSection7W0)ofDivi-
I�n SWIMMING POOL ELECTRIC
109
E O S ebe Was,for th alleged exemption.Any violation V exempt 70315 by any N
0 5 the bash for the alleged exemption. Any violation of Section mt m re any OUTLETSSWITCHESFIXTURFB
11w hundred
u applicantforapermit subjects the applicant to a dull pewltyo(nat rtnre than
live h�n s ownerbn he pr.
of NEW RESIDENTIAL ELFCTR SQ.IT.
.n ❑I,asownerlldotproperty,or my employeewith wages rtheir sole STORMS TYPE CONSTRUCTION
C compensation,Boston.he
rafingov,�and the Cne:TheCure,iii not intended n'or offeredLaw
Y O sale(Sec 7014,Business and f property
rope ty Cube:The or improves
s Llreve Taw
does not suchpply arko an owner of throng hiswho nbuilds
mploy mproAidedi thereon,and OCC.GROUP RES,UNITS
44
who daesuchwarktinthimself edorofferedowne.If,howeees,ver,
pr,thebuildtwch
improvementsare not Intended earofco fpreile.th ownereg deer ill have TOTAL:
Improvement Lssold withinpneyearofcompidlorythe owner-bu0derw111 have
re den of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE plop zDDNF. APN
as owner of the property,am exclusively contracting with licensed
ontra u.I..o neon the pmjed(Sec.7044,Eunice.and Pnifenbsu Code: PERMIT ISSUANCE
Contnnor'e License Law does not apply to an owner of property who
this or Improves thereon,and who contracts for such p(ujedALTER-DRAIN with a DRAIN&VENT-WATER BEA)
A,➢t[actor(s)licensed pursuant to the Contndcr's License Law. BACK FLOW PROTECT.DEVICE I FEE SUMMARY
LJ ec I am exempt under SB&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N r i. '1
OUTSID
Owner _____Date RECIIDPf p 3s
s WORKMAN I have.COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑I hereby orf m that I have•.rtlarate of consent to pythn ore,or RECEIPT Y
certiarab p(Wprken CompenseHon[nsunnce ora certlfktl.pythereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEF. Y N
3800,Lab CJ
Policy N GAS F.A.SYSTEM-OVER 4(EA) DENG DT p
Com any BUILDING DIVISION FEES
❑Certified copy b hereby ci formatted. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Ccrtlaed.py b(lied withhthe
e my Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCEgEwFR-SANITARY-STORM EA 2XXT Date Remi tit
(Thlssenion need nc46e complded If the pemdt V fm one hundred tlollan
(s1IcmlessJ WATER HEATER W/VENT•/ELECTR ENERGYFEE Y N
I ll nor emplhat oy
any perhe son in annce tmannerhe work so as to b comehis esubjecmit to booed,
I shall not empipy an/person In any manner.m to become subject to the WATER SYSTEM/TREATING
Wprkcan Compeentlon Laws o(Gli(omla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi Ht
Z � N077CE 70 MPLICANT:IL after mWng this Certillcate of Exemptlory you
shwld become aubpct m the Workers'Compensation provisions pf the Labor TOTAL:
W N Code,you must forthwith comply with such provisions or thio pemdI shall be L BUILDING
FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL IherebyafOrmthat there is a construction lendingagency forthe performF TOTAL: ELECTRIC FEE
Z ance of the work for which this permit b bsued(Sec.3092,CIV,C) c� a�
ED O Lender+Name PLUMBING FEE
IL 1,- Lender's Address q'rv, MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1cerilythat l haveread this application and statethattheabove Information
1 b.rrect.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE—PAID'
} W relating to building construction,and hereby authorize representative ofthts
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH, Date RecCl tic
— (We)agree to save;Ind emnlfy an d keep harmless the City of Gportion P
against liabWties,judgments,amts and expenses which may In any myaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
agai saki City in consequence of the grant ing of this permit.
AIR HANDLING IINRC(DYER IO,WOCFM) CONSTRUCTION TAX
SignatorsmAppliant/Contrano Dat' EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATER L,DISCLOSURE
Will the applicant or future building oc t store or handle hasardous HEATING UNIT(TO 100,000 BTU) Date Recel [H
malerlal as defined by the Cupertino Munldp ICode,Chapter9JZmdthe -
Iiealth and Safety Code Senlon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant or tum building occupant usecqulpmmtmdevim VENTILATION FAN(SINGLE RESiD) ISSUAMWE
whichemith..a .usair.ntaMmn,sasdeamdbythe Bay Arca Alr
• Quality Management District? BOILER-COMPORE OR 100,IXq BTU) - Apis I
4 Ye y No (�A�4M� �?iGtl'fL
haveread teeth& pry Codr,Sectionsls emontsundernd 255 . 1 of BORER-COMP(OVEi 100,0(10 BTU)
the Gltand to health&building
Code,SMION2550.5,ve a Land,that
understand that if the notify
the occupant ofnot
emclucurrently
entnts which
that b iset NEW RESIDENTIAL MECH. SQ.IT
responsibility to iwity ce notify the occupant of the requircmenb which must be caret
prim 1p Issuan.of a Certificate of Oc.panry. '
Owner or authodud agent Data ISSUED BYxe; ' /)r�/{T
TOTAL: =LI '
OFFICE COPY
:,1..
SEWER CONNECTION PERMIT NO.SERIAL P 15153
elk
CUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No.............. Lot No.!?.r.
20065 Stevens Creek Blvd. A.P.N. Bk. ...... Pg..2.Z... Par,030„
Building C
Cupertino, California 95014 1
Phone(408) 253-7071 Date... ��G?.T.......... ........, 19.��..
C
The undersigned,being the owner(or owner's agent)of the property located at .../<: ���1�..... C 7? .,��, C.......
.../„7.S/.....•../..... r, f!1� rrd.............................................................
consisting of the following TYPE OF BUILDING: v
Residential: Single family............ Multiple....X..... No. Units....7-
Commercial............
'Commercial............ Industrial............ Other............ No. Units............
does hereby request a permit to connect to the sewer system of the Cupertino Sanitary District.
In consideration of the granting of this permit,the undersigned agrees:
1) To comply with all existing regulations and Ordinances of Cupertino Sanitary District and all future regulations and
Ordinances which may be adopted.
2) To maintain the house sewer(that portion of the sewer within private property)and to provide access to the lateral sewer through
a cleanout raised to grade at the property line or at the limits of any existing District easement. (Note—Detail J)
3) To acquire a permit from the ...t�� ev"...!;r'�� S- ' ,d,,,,,,,,,,,,,,,,,,,,,,,,, BuildingDepart-
ment and obtain inspection and approval,by said Building Department prior to covering of the work or use of the sewer.
4) To first expose and inspect for serviceability the lateral sewer prior to starting construction of the house sewer.
Property Owner's Name...91f1e...... ......... TelephonedF�. `� 3 2 �..t Z.5e�
........................
Mailing address if
different from above..... ?.... f117f 1//A ...
!i f.... v
By..,..
. t ......h f........:. !,ZI'-•�
...............
F1A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above
property.(Note—See Detail l)
FEES:
Connection Permit Fee �or
Sewer Service charges to June 30, 19!�;?�,$.za. 7...../mo. x/L Mo. • ...
Inspection Fee for backflow protection device
Gt9
TOTAL $ / 6 ,--
ceipt of$.... acknowledged and permit granted. MARK THOMAS &CO. INC., Dict Manager-Engineer
NOTE:
E: '
NO physical connection of the house sewer By. .....� .......................
to the lateral sewer shall be made until writ-
ten permissdon is received from the District. NTE:See Details on other side of this permit
CUPERRNO SANITARY DISTRICT
NOTES: All valves to be accessible and maintained by Properly Owner.
Overflow point at least twelve inches(12") below lowest finished
floor containing plumbing.
Kelly Valve Installed of Property Line to be readily removable
for Lateral Sower molnienance.
J
w
Finish Flo r Level Finish Floor Level 6
3 rvE Kelly Valve " , S
Finish Grade NL
Ads Kelly Valvel _s.t
Valve Access E
01
with Vented C er �E Volvo Access Bar
Backwater Valve
Fy_R
Figure I Figure 2 Figure 3
Kelly Valve- Below Surface Backwater Valva—Normally Kelly Valve-Above Ground
Inslallalian-Shown or reauired installed al shallowest point nlMilmian Shown Installed
Property Line Cleououl. along House Sewer between close to building.
Property Line and building.
OE TAIL
STANDARD BACKFLOW PROTECTIVE DEVICE INSTALLATION I
Distance o-am E 10 be as
dpea as practicable
.
J
lio Removable Cl....n Plug
ou
o. Finish Grade
Wye for Riser w
Sewer Cteanout Boa with Lid a be accenIbis
and maI tainea by property owner.
Short length Rlsar Pipe
A dept.' coupling I/8 Bend
_ FLOW
Lateral SewerHouse Sewer
.a------`-fl' : � I
TEnimem slope determined by Building Department.
Lateral Sewer Cleanout to be same
size as Lateral Sewer.
DETAIL
STANDARD CLEANOUT FOR LATERAL SEWER J