04010124 (2) g CITY OP CUPERTINOnn,�'
BUILDING DIVISION PERMIT ,CONTRAC#TOR6INF.ORMATION j
o, ,'fita,✓7c'i `+ .',8T t r i
BUILDING ADDRESS: ABLESEPTIC PERMITN0040I0124
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONT ACTOR'S DECLARATION O O O
e I hereby affirm that l am licensed under provisions of Chapter Y(commencing - Job DESCrI
n<u with Section 7000)or Division 3 of the Business and Professions Cade,and my license is GY�RBtl
in mueclarsforce de — �5 SEWER/ABATE SEPTIC
i'n= License Clens Lic.x
=_in Dart —Contractor �T L FEB 5
a ARCHITECTS DECLARA OR N O 2004
U
I understand my plans shall W used u public records
Licensed Professional
OWNER-BUILDER DECLARATION BUILDING
<S 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following ociu m.(Section 7131.5.Business and Professions Code:Any city Or county
K m tai which requires a permit to construct,alter,improve,demolish,or repair any structure
LZi prior in is issuance,alsurtquires theapplicant Nor such permiuo Glc aligned statement
Ezp that he is licensed pursuantto the Provisions of first Contmctof's license Law(Chapter 9 Sq. Ft. Floor Area Valuation
y1- (commencing with Section 700(h)of Division J of the Business and Professions Code)tar
i Nat he u exempt the iffom and the basis for the alleged exemption.Any violist an of -n,oi int ia� A
Section 7031.5 by any applicant for a permit subjects the rapplicanuo a Civil Penalty of 3s>B rad W�DSr00 Occupancy Type
not mom Nan five hundred dollars(S5B0). P Y yP
p 1,as owner ofthe property,or my employees with wages as their vole compilation,
will do the work,and Ne srlsi is not intended or offered for sale(See.7044,Business
and Professions Code:The Conractor's License Law dors not apply m an owner of Required Inspections
progeny who builds or improv,thereon,and who doessuch work himself or though his
own employes,provided that such improvements are mH imended or offered for via,If,
however,Be building or improvement is sold within one you of mmpletlon,the Owner.
builder will have the burden of proving Nur he did not Wild or improve for purpose per
salt.).
1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7044.Bus and Professions Code:)The Contractor's Li
rue Law docs not apply m m owner of property who Wilds or improves Neuron,and
who contracts for such projects with a contractors)Iiccrsed pursuant to dm Corrosion's
License raw.
I am exempt under Sec .B&P C far this,sazan
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing dalaratiam:
1 have and will maintain a Cenificam of Consent to ulr-insure for Workers Compete
737M
ion,u provided for by Section 37W of ds labor Code,for the perforations,of dre
rk for which this Permit is issued.
1 have and will maintain Workers Compensation hsurna,as required by Section
of the labor Core,for Ne performance of the work for which Nis permit is issued.
y Workeis Compensation Insurance artier and Policy number art:m,:6:f4-l1 r,„ard Policy NO.:15 6157—e-7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
rThh satire need not he completed if t1te permit u for mac hundred dollar(S1(ad
las.)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any pormn in any manner sir as to Weomc subject a the Workers'Compensation
Laws of California,Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should
become subject to the Workers Compensation provisions of thc laMu Code,you must
., O forthwith comply with such Provisions Or this permit mall W deemed mvoked.
z Vy CONSTRUCTION LENDING AGENCY
[-� I hereby affirm that there is a construction lending agency for the performance of
a the work for which this Pernit is issued(Sec.3097,Civ.C.)
W� Q Lender's Name
2 Lendcri Address _ f
U C:) 1 calory that 1 have mad this application and sum that the above information is
ly F correct.1 agree to comply with all city and county on inances and stale laws slating to
U building construction,and hereby auhodm mprcunutimen of this city to enter upon the
r W
Above mcntioncd property for inspection Purposes.
(we)agree to save,indemnify and keep harmless the City of Cupertino against a�
Hh
bailcnsequence at
cosyindof this esmit, mayinany way acerae againstlaid City )
U z in consequence of NC granting Of this permit oJ/
.- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:s4toza Da
SOURCE REGULATIONS.
,2d3-en N 1 -27-aH Re-roofs
Signature of ApplicanrConraefor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Cook,Chapter 9.11.and the Health and Safety
ode.S❑de255J2a)?
Yes Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or Future building Occupant tax,equipment ordeviced which If a roof is installed without first obtaining an inspection,I agree to remove
lit havardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
isricrl
❑Yes AN.
1 have real the haaarthausmamrials requirements un&,Chapter 6.95 of the Califor-
niaHealth&Satctycode,Soctuds 25515,25533 and 25534.1 undcrsmM that ifthe Wilding
does not currently have a anent.Nat it is my responsibility to ata il'y the uaupant of the
'requimmcnts which must W mat poor to issuance of a Cenifeam of Occupanry. Signature of Applicant Date
Owner tar agcm ores
O[`� z7 e All roof coverings to be Class "B" or better
r authorized
.. � -. " --,:�.�' _„� -+•.yh.-r�V: J -, .�l+tiL... ,�...rr-.•.--^w..v-;.--••!..-.....A^ . ..� :.r.(..A.=": .- - _
PERMIT P$ 6 6 7 2
CUPERTINO SANITARY DISTRICT
Santa Clara County
20065 Stevens Creek Boulevard, Building C
Cupertino, California 95014
Telephone 408-253-7071
CONNECTIONPERMIT
( /�
Date ! � r r� 'l. 1 G t ! /• t'�iGL APN: Book�26 Page?Z Parcel
ROS/PM/Tract No. Lot No.
Property Owner: C��GL L<IGG1?�r� l�
Mailing Address:
]Gib �Jlflrf Alt i D
0111!";'x'11 t C t (A t1 G014- 14
2 7 2004
•M tt (��
(VWe),being the owner(s)(owner's agent),hereby make
!tm.akke application for connection of the at:
t a ► h!V E A r.f io . c P I`E rl (v)V consisting of the following Type of Buildings:
Residential: Single Family Dwelling; Multi Family Dwelling_; No. Units
Commercial ; Industrial ; Other ; No. Units
Do hereby request a permit to connect the sewer system of the Cupertino Sanitary District.
IN CONSIDERATION OF THE GRANTING 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 serviceable cleanout to grade
and accessible located within five feet(5')of the point of connection with the Lateral Sewer(that portion of the sewer in the
street right-of-way of District easement. ��Y(J 7 {1
3.To acquire a Plumbing Permit from the (AT'r of ��111 (f. 1 11\10 ,Building Department and obtain the required
Building Department inspections and approval prior to use.
4.To expose and inspect for serviceability the Lateral Sewer 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 connect to sewer within one(1)calendar year from the date of issuance of this permit.
7.To call UNDERGROUND SERVICE ALERT(USA))qq1-,8y0p0-2-2ry7-2600,at least 48 rh-o/urs prior
yto starting construction.,/ A'
8.SPECIAL PERMIT CONDITIONS: I6TW 1 1^7'1 l�+rl , I l nt.c �[(M p i r'+0 1 11 11+}r�`� N-
(44 l PSN N4(:a It- kt- x'17) .
A BACKFLOW PROTECTIVE DEVICE shall be installed to protect 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: ,1
Serer Service Charges to June 30,7144- /�
No. Units x$-1t C//month x +t+• no. months '?J 1 iy. (31010)
Backflow Protection Device Inspection Fee (31020)
Connection Permit Fee: 5 76 " 1/ (31020)
Additional Connection Fees ( )
Total: �Ut:!', ��
Considerations and Considerations of this Sanitary Sewer Connection Permit with attached Exhibits, are hereby agreed to
and acknowledged by the undersigned Owner(or Owner's Agent). Failure to comply may result in termination of permit.
Acknowledgement:
Owner's Agent:
p N (If Signing for Owner Please Print Your Name)
Receipt of 2 G iacknowledged and permit granted.
MARK THOMAS & CO., INC.,,district Manager-Engineer
Revised 5100 NOTE: See Details on other side of this permit
„
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
du not to exceed five(5') feet. '
J
m Removable Cleanout Plug
as
0
o_ Finish Grade
Wye for Riser
Sewer Cleanout Box with Lid to be accessible
and maintained by properly owner.
Short length
Riser Pipe
Adaptor coupling 1/8 Bend
m-
Lateral Sewer House Sewer
Lateral Sewer slope House Sewer slope
determined by District determined by building deportment
— CLEANOUT TO BE SAME SIZE AS LATERAL SEWER—
Notes:
1. Distance from the property line not to exceed five(5')fest.
2. Properly 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 dadaaiaranal Reil,valiant
Accented By All dadidicuoni
FIGURE I FIGURE 2 FIGURE 3
Inelolled Below Grade Inilalled Below Grade Installed Above Grade
Shawn Beleetn Street Riabl-ol-Way to Building Shoe.At Properly Une Cleanoul Shown Adlo[enl To Building
Requires Regular maintenance Z Requires Minimum MainlenonCt Reamree Minimum MainlenonU
Valve To Be Removable Valve Should Be Remavobb
r VALVE ACCESS BOX FINISH FLOOR
W with/Vented Cover
O l vel el FINISH FLOOR
KELLY VALVE
^_f niih Grade
VALVE ACCESS BOX
KELLY VALVE i
rHin.,h Grade Rniih Grade
C
^ i
BACKWATER m
VALVE
/I
FLOW
FLOW
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.
'AN 6 20004
DER:
CHH:
File:
CUPERTINO SANITARY DISTRICT
20065 Stevens Creek Blvd., Bldg. C
Cupertino, California 95014
(408) 253-7071
"ON-SITE REQUIREMENTS-OVER THE COUNTER REVIEW"
File: CuSD MOP
Building Dept-Cupertino
Community Development Department-Building
City of Cupertino
10300 Torre Ave.
Cupertino, Ca 95014-3202
_lC
AVMPOKI S .
RE: Subject: YJ ;� Gc��lheL �lW
Approved For Issuing Name: . eUL 0, , P
Building/ Plumbing Permits ;. .Address: .. I 0I6.5 6MPIP6, Ai5.
APN: _�?ZC— _2�7 ."O?o
eControl/Plan Ck No.:
Permit No.:
Cu CtAr- r6N WIT 16672,
The Cupertino Sanitary .District has reviewed the plans for the subject project:
❑ No additional conditions/requirements by the District.
❑ Sanitary sewer is available and the existing building is connected to sanitary
sewer, see conditions/requirements listed below.
Sanitary sewer is 04t) available, see conditions/requirements below.
❑ Sanitary sewer is not provided by the District, please contact the City of
Sunnyvale at (408) 730-7510.
The following Conditions/Requirements are made:
Install new Property Line Cleanout or locate and raise to grade an existing
property line cleanout. Cleanout shall be the same diameter as the street portion
of the service lateral (Minimum gravity lateral is 4" diameter).
Video Inspection 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. District to provide Building Department with Written Notification
upon completion of Inspection.
Page I of 2
a "ON-SITE REQUIREMENTS-OVER THE COUNTER REVIEW
TO1 fin' VI J j71 v�
RE: Subject:
Name: 2004
Address: CIO '- )(6.
APN: 0M
Control/Plan Ck No.:
Permit No.:
s� (Ak6elf'QN fWIT #�1667Z
❑ Inspection of Street Portion of Sanitary Sewer Lateral by the District, Please Do
Not Inspect and onsite construction prior to clearance in writing by the District.
❑ Owner to have a Civil Engineer fix the lowest finished floor elevation, with
plumbing, to the rim of the next upstream manhole. If the lowest floor with
pluiribing is less than (1') foot above the rim, a Sewage Pump may be required.
❑ Cupertino Sanitary District Fees or Permits are required for the subject
improvements Please Do Not Issue any building permits.
❑ Plans shall be reviewed by the Industrial Waste Division of the San Jose/Santa
Clara Water Pollution Control Plant Phone 945-5121 for questions and to
schedule a plan review appointment. Please Do Not Issue permits until
pretreatment recommendations have been forwarded to you by the District.
❑ Verify existence and serviceability of an existing backflow protective device.
a Break areas authorized minor electrical appliances only. (No commercial
disposal or commercial dishwasher installations.)
Other: TWN Q MAI /
Stl wae7£orm surface or roof drains, other general surface runoff water or condensate
form any residential HVAC equipment shall not be discharged to the sanitary sewer.
NOTE: Contact CuSD for `°OFF-SITE REQUIREMENTS"
By:
Pase 2 of 2
CITY OF CUPERTINO
'' REPIPE/SEWERS/MAIN SERVICE
CUPEkTINO PERMIT APPLICATION FORM
APN #�2� z Z� Date:
Building Address:
10 106 A'�
Owner's Name: Phone#:
Contractor: Phone: License#:
AO)f i clYl n J 377 _ q ,--' -
Contacq Phone: QZ J2 Cupertino Business License #:
Building Permit Info:
Bld Elect ❑ PIU262
JobDescription:
j-c,u.-e� vP A a.7r 5 ePt) c
Residential Commercial ❑
Cost of roj t
�0aq /coo
Qty. i
A li e Fee ID Fee Description Fee Group
PPERMTTFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
\�0 SAN I T-4,p`,
�AfSTRICT MANAGER-ENGINEER V BOARD OF DIRECTORS
MARK THOMAS&COMPANY,INC. CURTIS B.HARRISON
DAVID E.ROSS JOHN M.GATTO
Fsr4B[I S H EO ,�'y DR.JOSEPH F.BROWN
DISTRICT COUNSEL WILLIAM A.BOSWORTH
ATKINSON NO FARASYN, LLP 20065 STEVENS CREEK BOULEVARD,BLDG.C WENDELLH.K RR,JR.
HAROLD S.TOPPEL CUPERTINO,CALIFORNIA 95014-2350
(408)253-7071 PHONE • (408)253-5173 FAX
File: CuSD—MOP
Building Dept. —Cupertino
Community Development Department—Building
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014-3202
Subject: Sewer Installation
Name: Carol Woodard
Address: 10185 Empire Avenue Lo W1642
APN: 326-22-029
Control/Plan Ck No. Cu SD Connection Permit No. 16672
• Videotape and Property Line Cleanout inspected.
No additiCalc9on ons quirtsthe District.
Inspecto ...................................
Date: .1...v: ..o.d
cc: Homeowner
SUPPLYING SANITARY SEWERAGE SERVICES FOR: CITY OF CUPERTINO, PORTIONS OF THE CITIES OF SARATOGA, SUNNYVALE, LOS ALTOS AND SURROUNDING UNINCORPORATED AREAS
www.cup et lin osonitorydisirk L con; (/
Q�`�0 SANITgB/�D,�f
DISTRICT MANAGER-ENGINEER V -r BOARD OF DIRECTORS
MARK THOMAS&COMPANY,INC. CURTIS B.HARRISON
DAVID E.ROSS JOHN M.GATTO
Fj)481I S HES DR.JOSEPH F.BROWN
DISTRICT COUNSEL WILLIAM A.BOSWORTH
ATKINSON■ FARASYN, LLP 20065 STEVENS CREEK BOULEVARD,BLDG.C WENDELL H.K RR,JR.
HAROLD S.TOPPEL CUPERTINO,CALIFORNIA 95014.2350
(408)253-7071 PHONE ■ (408)253.5173 FAX
File: CuSD—MOP
BuildingDept. —Cupertino
�orJ.
Community Development Department—Building
City of Cupertino
10300 Torre Ave.
Cupertino, CA 95014-3202
Subject: Sewer Installation
SName: Carol Woodard
Address: 10185 Empire Avenue
APN: 326-22-029
Control/Plan Ck No. Cu SD Connection Permit No. 16672
■ Videotape and Property Line Cleanout inspected.
No additiCalco itions/requirements by the District.
InspectoU.... .. 5..............
Date: .. . l
cc: Homeowner
SUPPLYING SANITARY SEWERAGE SIRVILES FOR: CITY OF CUPERTINO, PORTIONS OF THE CITIES OF SARATOGA, SUNNYVALE, LOS ALTOS AND SURROUNDING UNINCORPORATED AREAS
www.cup ertinoson itotydistrict.com �R