22604 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
- Building Project Ideneflcatlon -PERMIT NO.
ll
Bu-ujng S/6 , 3 22604
(I 0
Wa/M��raOne:
a'N -I L x f�-�r p•v L 27 CITY OF CUPERTINO-BUILDING DIVISION
Co acto' dS{- ��Ig.Np, APPLICATION / PERMIT V—lb
Asect/Engineer. Lie e No:V BUfLDINC ELECnUCALPLUMBING-MDCHAMCAL CA7FGORY CONTROL#
QTY ELECTRIC PERMIT FEC BUILDING PERMIT INFO
-20 Address . O w 1'FRhIITIS"a1JANCE ❑ 1:1 � 1-1LICENSED CONTRACTOR'SD WRATI CRATION
I hereby affirm that l am bcrosed under provisions of Chapter 9(commenc APPLIANCES-RESIDEMTAL JOB DESCRIPTION
Ingwlth Saou, 7000)of Divlsio0e(theBual����ne//xyx.�and ProfesslonaCode,anci my
Lt .e is is(ullls andti died. /r/ PANELS
Lion Ch GG CC.... 'Ed siW� La-1 a'IKs�
Date /&.Contra,der UP TO 2DO AMPS
ARCHITECTS fECMURTTION 201-1000AMPS
reluu��Zp I understand my plans shall be used as public reevrds OVER 1000 AM[5 .F E/SQ.FT.
LicensedPrefesslo.i SIGNSELFLTRICAL P U T> E R
6 Gaff++ OWNEReBUILDER DECLARATION xempt from the Contractors License Law for the—SPECIALCIRCUfT/MLSC
pppQ countygreawn.(Section 7031.5,sapermittoroslnenandt,improve,
Code;Any city or /
� t"� county which rcqulresapermlttoconst.ct,alter improve,desnlbh,orrcpair TEMP.METIER ORPOLE INS(.
any stmtlure prior to lt.l.suance,also requires/he applicant for such permit to
IC)WPR DEVICES
O fan a signed statementla that he la licensed pursuant to the provisions of the
don 3 oftheBusines and(ChapterPrdesdo Code)(couraencingarthat with xSection herefof Dhd- SWIMMING POOL ELECTRIC VALUATION
H�O< debasis for
the alleged
Pmfemlon. Any
(fedi pt therefrom and
•-1 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHPSFIXTURES
applicanlfora permlbubjectalheappllcanttoadvii penalty olno[snrcthan
F. five hundred dollars($.500). NEW RESIDENTIAL ELECTR SQFr. STOEES —TYPE CONSTRUCTION
7 6 ❑1,as owner of the property,or my employees with wages as their sale
compensation,willdo the workand lhestmature is em intended or offered for
❑ sale(Sec.7044,Buslnesa and Pmfesslmu Code:The Contractor.License Law
don.notapplytoanowner ofproperty who builds orimprove,thereon,and
0.0. who doe.such work hlmselforthrough his own employees,provided that such OCC.GROUIP RES.UNITS
Improvements am not Intended mo(fered forsale.If,however,lhebvilding or TOTAL:
improvement bwld wlthlnomyearo(completloNtheowner-bullderwill have
tlft,r,den of proving that he did nor build or Improve for purpose ofaale.). QTY. PLUMBING PERMIT FEC p1.00DZDNE APN
Lf I,as owner of the property,am exclusively contracting with licensed ptnMlT ISSUANCE.
contrectorsto construct the project(Sec.7044,Business and Professions Code:
11u Contractor's License Lw does net apply to an owner of property,who ALTER-DRAIN kVENT-WATER(EA)
builds or Improve thereon,and who contracts for such pt jets with a
Nlicensed pursuant to the Centractcr's Lt...Law. FEE SUMMARY
I am exempt under Sec. , B A P C for this reason BACK FLOW PROTECT.DEVICE
DRNNSFLOOR BOOP,AREA,COND. 12 V
SANITARY Y N
. Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FDfTURFS PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have• lrtaran of consent d pythemof ora RECEIPT#
rediflcme of Worken'Compnruatlon lrouuranee ora rertl(led copylhemo(LSec. GAS EA.SYSITM-1 INCA OUTLETS PARK PER Y N
Poli,Ipb RECEITa
Com anv ), �••� GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
wartlfleei copy is heed with he city CREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
f lCerll(led copy b filed with the city inspection dlvldon.
$`�� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY
phla.ectionneednotbecompleted Rtheper t b lorem hundreddollan SMRM EA.20aFT. ,pp Date RCC01 t#
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I amity that In the performance of the work forwhich this permit la issued, —
I shall not employ any person In any manner so as to become subject to the WATIR SYSTEM/TREATING PAID
Workers'Compensation Laws of California.Date
Q Z Applicant Date Remi t#
Z O NOTICE TO APPLICANT.H,after nuking thisCertNcateof Exemption,you NEWRESIDENFTALPLMB. So.FI'.
should become.ubject to the Workera Compensation pmv0lom o(the Labor TOTAL:
N Code,you moat forthwith mmplywlth.uch pmvLlonamthl,permit shall be
deemed revoked. BUILDING FEE
W
C CONSTRUCTIONLENDINGAGENCY SEISMIC FEE
1 hercbyalB rm that there is a construction lending agency for the perfom- ELECTRIC FEE
Z 'ante of the workfor which thisperMt is isated(Sec.3097,Civ.C.) TOTAL:
U O Lander.Name l ,OD PLUMBING FEE
LL r' Lender.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL PEE
O W
UItenlfythtl have read lhlsappllcallon and statelhat the above information
a 9cormd.lagreetocomplywithallcttyand county ordinances and state laws PERMITISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives of this
F L city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Rt#
_ (We)agree to save,Indemnify an d keep harmless the City of Cu per lno P
eCel
aga Inst liabilities,judgmems,rosleand expenses which may In any way accme AIR FLANDUNG UNIT Q010,000 CFM) SUBTOTAL:
sig sold City ....quenre of the grant ing of this Permit.l _- 6 AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
.tore of Applicant/Contractor - - Date EXHAUST HOOD Ball DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplica est orfttu re build Ing occupant store or Its rid le hazardous HEATING UNIT 00100,wo BTU) Date
material a.cleaned by the Cupertino Musldpa l Code,Chapter 9.12,and the ReCCi I#
Health and Safety Cade Sectlan 25532(a)7 HEATING UNIT(OVER 100,000 BTLJ)
❑ ye. TOTAL: 1700
Will the aorb No .pplicant future bvllding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air.rtamlnsnts as dd.d by the Bay Area Air
• Quality Ma.gemenl District? BOILER-COMP pTIP GR 100,000BTU)
Ys No
have read the hazardous materials requlrementsunderChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safely Code,Berlin.75505,25533 and 75534.7
understand that if the building does not currently have a tenant,that it b TI
my NEW RESIDENTIAL MECH, SQ.FT.
reponsib0ity to notify theocupant ofthe requmememswhlch must be met
prior to Issuance of a Certificate of Occupancy. tI
Owner or authorized agent Date ISSUED BY: .a
TOTAL:
OFFICE COPY
SERIAL15181
SEWER CONNECTION PERMIT NO. Pv
ICUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No. .... Lot No... ......
20065 Stevens Creek Blvd. A.P.N. Bk...'S. ...... Pg...-'.>!-`-... Par. /.7...
Building C
Cupertino, California 95014
Phone (408)253-7071 Date.... ................ 19��.�..
The undersigned,being the owner(or owner's agent)of the property located at .........................4..............................
6_1 epkl..0.......................................
consisting of the following TYPE OF BUILDING:
Residential: Single family.....X.... Multiple............ No. Units.....I......
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 .. .'..�'.'°).....C'�.....�'.p �14.!'l.(.'............................. Building Depart-
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.A.A.4?�✓..C>7.....f!1447./F.!7.Y.,/-/ ..... Telephone.. ......................
Mailing address if
different from above.....�.«"wt. ................................................................................................
Byfe-..................................................
❑ A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above
property.(Note—See Detail/)
FEES:
V
Connection Permit Fee
Sewer Service charges to June 30, 19 .(.,$..../..(..'..e../mo. x. mo. I
Inspection Fee for backflow protection device
TOTAL $
r r�
ceipt of$l.. .f�7.C'.... acknowledged and permit granted. MARK THOMAS &CO. INC., District Manager-Engineer
NOTE.See Details on other side of this permit.