24974 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO D➢f.RiNti-I,Ul`- .A. PERMTTNO.
CAL
BUILDING DIVISION APPLjCe�TION/PERMIT PING Pli IDENTIFICATION
.e III111,DIN1:1'HOJEC'1'IU16N'PIRICATION . 24974
BUILDING ADDRESS: 1 - SANITARY NO. APPLICATION SUI+ I'111A],DAE
1-'65D-, �AJ \ UNIT# IAT# /t J
OWNERS NAME: ONE: CO TRACTOR'S NAME: hIC NO:
T Yh I N/C CONTROL#
s ARCHITECUENGINF.ER: LIC NO: A ESS:` `' 3+ �L1 ❑
U l//• Jx.
ONTACf: PHONE: QTY. ELECIRICPHRMIT HE BUILDING PERMIT INFO
BLDG HLECT PLUMB MI?CII
PERMIT ISSUANCE ❑ E
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL. _ _ JOtiCRIPi'ON
q y�z Ihereby affirm thatton lice^mdond TOR'SsDECL RATI 9(commencing with O
F100 Senian]O(q)nf Division3of the Business and Professions Code,and mylicrnse is in PANELS
yUE full force and effect. 'y
F7 Dolense Lic.p 3?- UP T0200 AMPS
m¢ Dole Cnntmdor T �It;, 201-1000 AMPS
nd inARCHITECTS DECLARATION OVER I"AMPS
SU.PE'.FLOOR AREA
O z—M I understand plans shall he used as public records.
P y 1=IIS SIGNS ELECTRICAL.
Y� Licensed Professional
CSU OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
° C)t. I hereby uffrm that I am exiting,form the Contractors License Law for the
W 3tr-rFi�
following reasort(Sis,hum 703 1.5,Business and Professions CWe:Any city mcounty, TEMP.METER OR POLE INST.
5 which requires it permit m construct,elmp improve,demolish,ter repair any s[mcmre
priorlaimissuance,also requires the applicant for such perming file.signed statement POWER DEVICES I G-'
fl GO but he is licensed pursuant to the provisions of the Co^tncmr'a License Law(Chapter
4 9(commentrug with Section 7000)of Division 3 of Be Business and Professions CMB) SWIMMING POOL ELECT RIC [1�41 PUT
I+PA '
ION
My or that he is exempt therefrom and the basis for the alleged exemption.Any violation of DUTI PTS-SWITCITPS-Fl%TUHES
}
Section 7031.5 by any applicam for a permit subjects the applicant to o civil penalty of
a
W ,more than Gvehundrcd dollars($500). NEW RESIDENTIAL ELECTR _SQ.FT. DATE
pec ❑ 1,asownerofthepmpeny,ormycmploymswi,hwagesmthcirsolecompemmion, T PECONSTRUCfION
pW,
ill do the wmk,anctm
thertmureisnot intendedminfiered forsale(Sec.]04q Business
and Professions Code:TTte Contractor's License Law does not apply in an owner of
progeny whohuilds nrimpmves Nereoa,and whodoumch workhimxlfnr through his
OCC.GROUP RES.UNITS
ownemr,thau,pingor improvement
is
sold within
one
inrandolmoffemd the owner-
however,illhav he burden
Essoldwithinoneyear of comovs,fo,theow^er-
bile.). will have the buken ofproving that he did tot build or improve for puryose of TOTAL'
a10).
❑ I,as owner ofthepropeny,am exclusivelycontracting with licensed contractors to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
construct Be pri(Sec.7041,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law aces not apply laan owner of property who bui Id s or i m proves therean..nd
whocomractsforsuch pmjec,s with.coaauct.da)licensed IF....uothe Comracmrs
License Law. ALTER-DRAIN&VENT-WATER(EA) PEE SUMMARY
❑ I am exempt under Sec. ,B&P C for Nis mmn BACK FLOW PROTECT.DEVICEDE FERS
SANITARY Y N
Owner Dale DRAINS.FLOOR,ROOF,AREA,COND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTA% Y N
)hereby affirm that 1 have a cenificam of consent m self-irsum,or a ceniGcam of RECEIFr#
Nets'Compensa,ion Insurance or ecmifid copy Hereof(Sec.38o0,Lab CJ FIXTURES-PER TRAP which PARK FEL' Y N
I all employees under this permit. GAS-EA.SYSTEM-]INC.4 OUTLETS RECEIPT#
Policy
copy,is hereby fumishd.y# BUILDING DIVISION FRES
Company GAS-EA.SYSTEM-OVER 4IEA) PLANCHIiCK TEP.
❑
❑ Cerified copy is Elect with the city inspection division. GRFASWINDUSTRL WASTE INTERCEPTOR GRADING ITE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
('Nis section deal not be completed ifthe permit is faro.hundred dollars(5100) SEWER-SANITARY-STORM F.A.200111'. ENERGY IEE
mless.)
I cenify that in the performance ofthe work for which this permit is issued.l shill WATER HEATER W/VHNT/HLECIR
no,employ any .no in any manner ro as to lace. �b1y to h Workers' PAID
C�mpenrithimn la—wso—f Cut t,—a.. Dite U_j - WATERS STEM TREATING Dam Receipt
Applicant
NOTICE TO APPLICAKf:If,after makiExemption,You shtwld - RESIDENTIAL PLMB. SQ.FI'. TOTAL: s
4 become subject to she Workers Compensation Provisions of the Labor Cade,you mus, s
jforthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
0. (� CONSTRUCTION LENDING AGENCY SEISMIC FEE '
Z I hereby^(Grin ilm then is a construction lending agency for Be,performance of _.
V O the work for which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
lend&,Name
Ii PLUMBING PER
p Lender's Address QTY. MECIIANICAI.PERMIT PEE
V I certify that 1 have read,his application and state that she above information is
correct.legree to comply with ell city aM county ordinances and scam laws rtlating to PERMIT ISSUANCE MECHANICAL PER
F-' building conswction,and herebyauthotimreptesemadvesofthiasity mrnrer uponthe
V 7 above mentioned properly for inspection purposes. ALTER OR ADD TO MCCH. CONSTRUCTION TAX
C (We)agree to save,indemnify and keep humblest the City 01 Cupenmo inxI
liabilities,jidgments,cstsandexpmiscsishichma ' ycc AIR HANDLING UNIT(TO 10,050 CFM)
in 21u m`u gof Nis pe `//
// AIR HANDLING UNIT(OVER 10,000 CPM)
96^mmeo ppl¢ant/Conunaor Dela EXHAUST tI00D(W/DUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO BTU) Data Receipt#
Willthe applicam at far.building meopamstoreor handle hamrdium material HEATING UNIT(OVER Be."BTU) 1:
as defined by the Cupcni^o Municipal Code,Chapter 9.12,and the Hailth and Safety
CM,,Section 25532(x)?
El Yes El No VENTILATION PAN(SINGLE RCSID)
Will,heapplicanmrfmurebuildingoccupant use equipment ordevitts whichemit
BOILER-COMP OHP OR 1100,000 BTU) ISSUANCE DATE
hisommus air comaminmts as Eefnd by the Bay Area Air Quality Management BOILER-COMP(OVER 104000 B'N)Jibpp9g pp
suits? IT W
! I ❑Ves ❑No NEW RESIDCNTIAI.MECH. SQ.IT.
1 have read the humadfelyCous Sections re05.255 3l under 14.pterlun 6.95 of the 151993
Californiaba Health&Safety Cade,Sections 25505,amen and 25534.I undersand he �QY
.if the building does not currently have a moot,that i,is my responsibility to votify the
occupant of the requirements which must Is,met prim to issuance of a Certificate of y
Occupancy. CIlY U+ LIN
Owner m amhotixed.gem Dam TOTAL: ISSUED BY:
PERMIT M5235
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:0:6:/P:M/Tract No. G/ 47 Lot No. SU
A.P.N.: BookPage 1LParcel Date
Property Owner: e?e", i'
Mailing Address: :5aw"�
(If different)
Telephone: r6.!�7-z9k;r
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at: 2/r�sZ
Oa��rs. Drivr"� ���✓��
consisting of the follow ng TYPE OF BUILDING(S):
Residential: Single Family x ; 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 4
Of Cii�aiA "'d Building Department and obtain
inspection and approval by said Building Departments rior 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-ot-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:
Connection Permit Fee: $
Sewer Service charges to June 30, 19,7-; ,$ /.S= /mo. x 3 mo.: $
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:_ z,`
Owner's Agent: SM n-#5 42
(print name)
Oa
Receipt of$ . ` acknowledged and permit granted.
MARK THOMAS& CO.,INC., District Manager-Engineer
by: '144
�2
Note:See Details on other side of this permit.