04020170 CITY OF CUPERTINO "' ---
BUILDING DIVISION PERMIT F CONTRa,CTQR TNFU�RMAIUN.,
BUILDING ADDRESS: ABLE SEPTIC PERMIT NO 04020170
ER'S NAME: PERMIT ISSUE DAM
NE: SANITARY N0. CONTROL N0.
ARCHITEMENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�I Op LICENSED CONTRACTOR'S DECLARATION O O O O
Job Deserip[ig�
1 hereby affirm that I un Iiconscd under provisions of Chapter 9(commencing
with an 7IXMpor Dlvlsion3oNUBu cuand Professions Code.and my license is ���'7��®
in ful�lfe red eRec
am SEPTIC
- con" r SEWER CONNECTION 60 ' LINEAR
ARCHITECTS non SEPTIC ABATEMENT MAR 1 7 2004
�.underaunJ mY Plans dull W usetl u tic record
7U
3 a
Licensed Professional
j
OWNER-BUILDER DECLARATION
Contractor's
13UI DING
d3 0 0 I hereby.(Sec on 1 am exempt from d r Conlns Cod License Law for the b ,Y
O o following museum. emit IID str Business and improve,
de oli Cole;Any oily or county
which requires n Permit re mires a aloe impmw,dmol0h or repair any udemen
prior wtat hoitsamad e,also PuMmLquiru ire applicant for suchpermiuorile a canse Law
(Chumenl
€� thenmeraicnwJpurnantW flue70l of Divionsm the ConusinesbLicenselsw.Code)9 Sq.Ft. Floor Area ValuahOA48O
$ (cot he is ang with Section 7fln d of basis
far of the egad meand Profusions Code)of 4 0
..
that he 4 emmpt Omrtfrom and the buil for sill alleged Gumption.My violation of
Section 7031.5 by any applicant for a permit subjects the applicam to a civil penally of APN Number {y OccuP aney �1'le
not mom than In hundred dollars($5001. p
❑1,u owner of Ne pmpeny,m my empioyeu with wage u their sole compenadon, 32619121 . 00
will do Ne work and thesuuctun is mAinu nded uroffered torture(Sm.ION,Busimen
and ProfeSaions Code:The Cmusam s Liaise Law doss not apply in as owmm or Required Inspections
property who Wild of Improves memon,endwher deomanwork hinnulfmthmugh his
own employees,provided that such impro runs aro not h mnded oroffereW fm Sale.Ir,
however,Ne building or improvement is mid within one year of completion.Ne owner
builder will have Ne burden of proving Nat he did not Wild or Improve for purpose of
me.).
❑I,As owoer of the property.am exclusively communing with licensed contraction m
comma Ne project(Sec.7044,Business and Profusions Code:)The Communes Lf-
cave law doer not apply as an owner of property who Wilds or improves themon,and
who corsets for Such projects with a comm icmr(s)licensed pursuant in tiro Conmmtofs
License law.
❑I am eumpt sande,Sec. ,B@P C for this tenon
Data
WORKER'S COMPENSATION DECLARATION
1 hereby from under penalty of perjury oro:of Ne fallowing declmdov:
1 neve and will maintain aCenffiuta of Consent m ulr-W un for Worker's Compcn-
usion,u provided for by Session 3700 of the Isbor Code.for the Performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,u required by Section -
3700 of the Isbor Code,for this performance of the work for which this pemft is name.
My Wolkeh CMar'nud InaUmV cariu and Policy number art:
Cartier. itrr0� Itry No.: ��
CERTIFlCATE OF EkEMMON FROM WOR —
COMPENSATION INSURANCE
(Th6 section need not W complemd IftW Permit Is forest,hundred dollar(SIM)
or sus.)
1 certify that in the p ufm onsom of the work for which this pe lir is hat I mall not
employ any perun in any manner so As m become subject to ere Workers'Compensation
Laws of Celifomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CeniOeam of Exemption,you should
become subject to the Worker's Compensation previsions of the Labor Coda you mum
.JO roMWrh comply with such provisions or this Permit Nall W deemed mucked.
y► CONSTRUCTION LENDING AGENCY i
F•' I thereby alum that then is a construction lending agency rear the perfumanm or
a > the work fur which this permit is Wood(Sm.3097.Civ.C.)
Q Lender's Name
z Lenders Addman
U 0 1 artily,in.,1 ban read this application and Soon that the 1Ww information Ire
il,E cortex I agree m comply with all city and county omirwaeund sou laws Muting to
0 building construction,and hereby audamm opremmaris,of this city in enter upon the
�D] move-mamivaed pmpcny for inspection purpose&
g� (We)agree to save,indemnify and keep harmless the City of Cupertino against
i�.
in liabilities.judgments,costs and expenses which may In any my seem against Said City `1 ,
L)"" in
APPLICANT PUNDERSTAN or Me Starting of-AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG —
Re-roofs
St Ap c onmactor am
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Wll theiapplicant or future Wilding occupant more,art harardous material
u fie by the Cupertino Municipal Code,Chapter 9.11,and Oct Health and Safety
de.Scam.2553no7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 17Nu
Will the applicant or future Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir hammus air contaminants u defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have real OR harardous materials requirements under Chapter 6.95 ofthe Califor-
niaHealth A,Seely each.Sections 25505.15533 wW 25534.1 undmeund Must R Ne,Wilding
deo rot currently haw a unanl.this it u my responsibilhy in notify the occupant of to
requirements which mum be pd a ora ifcate or Occupant Signature of Applicant Date
—2-7-661
o Tenant . agent Dam All roof coverings to be Class "B" or better
I. ogft at RC pERTY LINE —
FEB 27 2004 „
CIN
BUIL®
r }
EXISTING HOUSE CL
OO
CK
CL nn
ADDRESS: ?� ) on Ub,N CL
CO
DRIVEWAY
PROPERTY LINE
CO
SIDEWALK
GUTTER
w
FACE OF CURB I D=60 (ft)
o — LATERAL
SEWER LINE
STREET NAME:
SIDEWALK
� �p SANITgAp�, '
461,
DISTRICTMANAGER-ENGINEER V
-a BOARD OF DIRECTORS
MARK THOMAS&COMPANY,INC. CURTIS B.HARRISON
DAVID E.ROSS
JOHN M.GATTO
DISTRICT COUNSEL F�rAe[/$NEO "i% DR.JOSEPH F.BROWN
WILLIAM A.BOSWORTH
ATKINSON•FARASYN, LLP 20065 STEVENS CREEK BOULEVARD,BLDG.C WENDELL H.KERR,JR.
HAROLD S.TOPPEL CUPERTINO,CALIFORNIA 950142350
. (408)2530071 PHONE • (408)2535173 FAX
RECEIVED
FEB 2 7 2004
February 25, 2004 CITY OF CUPERTINO File\` CuSD—MOS'
BUILDING DEPARTMENT Buildir g Dept. —Cupertino\
Community Development Department—Building ApprO For IssuingCity of Cupertino
10300 Torre Ave. Building/%Mb4,permits
Cupertino, CA 9514-3202
. Subject: to abandon existing Septic systeinggn0vonnect to%e er
Name: Bemis -
Address: 21821
APN: 326-19-121
Control/Plan Ck No. CSD Permit No. 16678
0
The Cupertino Sanitary District ha,W reviewed the plans for the subject project:
• Sanitary sewer is available, see conditions/requirements listed below.
a
The following Condilions/Requirements are made:
m Videotape Inspe lion of the Property line Cleanout, Point of Connection and
Street Lateral is required prior to passing The City of Cupertino Final Inspection.
Owner to call District 48 hours prior to video inspection to schedule a District
Inspector. D19t"ct to provide Building Department with written Notification upon
completion ofispection.
Q
SUPPLYING SANIiAAY $EWE RAGE SFAYIr ES FOA: CRY OF (UPEAIINO, PO A110N5 OF THE OIIEf OF SA0.Ai0 GA, SUNNYYALE, LOf ALTOS ANO SOAP OUNDING UNINCORPORATED AREAS
www.r up a Ytin osun itur ydis trir L rom
Subject: To abandon existing Septic system and connect to sewer Sheet 2
Name: Bemis
Address: 21821 U&9
APN: 326-19-121
Control/Plan Ck No. CSD Permit No. 16678 rr
® ED
FEB 2 7 2004
CITY OF CUPERTINO
BUILDING DEPARTMENT
Storm water from surface.or roof drains, other general surface runoff water or condensate
from any residential HVAC equipment shall not be discharged to the sanitary sewer.
NOTE: Contact CuSD for "OFF-SITE REQUIREMENTS"
Yours very truly,
MARK THOMAS & CO. INC.
District Manager-Engineer
J 0TL,By David E. Ross
CHB:cv
If you have any questions or need additional information, please call
Carl H. Beckham at 408-253-7071.
cc: Bemis