24197 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification I
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Building Address: c
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Z 419
7
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OP CUPERTI40-BUILDING DIVISION
If PERMIT
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Contractor's Name: Lk.APPLICATION
ECTRICAtePLUMBING.MECIIAMCAL
CATEGORY CONTROL#
Architect/En neer:BUILDINGS
� LlcY
ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
I'FRMITISSUANCE
❑ ❑ Nil ❑
LICENSED CONT'RACTOR'S DECLARATION
Ihercbyafflrm that l am licensed under provisions of Chapter 9(mmmse
Inressi infelifor )af Divfiect. (the BuslnmandProlesaonaCode,and my
license la In luB force and dfeet
APPLIANCES -RESIDENTIAL
JOB DESCRMON
PANEIS
License Claes Llc.p
Date ContgctarUP
TO 200AMPS
201-1000AMPS
ARCHITECTS DECLARATION
I understand my plana shall be used as public records.
JOVERIODOAMPS
SQ. FL FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECDILCIRCUIT/MISC -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TBMPMEERORPOLEWSL.
/
TOWER DEVICES
following reason.($ection 7031.5, Business and Pm(esabm Code: Any city or
countywhkhrequimaper ttommtr Malter,bmprove,demolish,orrepalr
anystmu mprlortolts Issuance,abomquimstheapplianiforsuchper tto
file a signed statement that he Is licensed pursuant to the provisions of the
Contranar's License law(Clupter9(mmmencing with Section 7000) of Dlvl-
slon3af the Buslnm and Pro(mlom Code)orthat heIs exemp[Ihercfromand
the basis for the alleged exemption. Any violation of Section 76'31.5 by any
hent (ora permit athea II ttoa civil cul o(nd more than
PP per Tec applicant penalty
1" 112 I
gWPTMINC ]'DOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
hlj.[
I� V
AA ON'
NEW RESIDENTIAL ELECTR �'�' n—
dyed dollars ($500).
property, my employees wages •
owner of the ro or ti enwithwa as for
work and lhestmdurc t not Intended or offered for
P
I
TYPE CONSTRUCTION
s
(Sec.
(Sec. 7lon, Business
Bu sinessandf Cods: The Licensthemes law
property or improves
apply loan uraerofthroug ywho builds
apply
does who does mplc, mprovestbereoRand
whodonsuch work a hisown employees, provided that such
OCCGROUP
RIS. UNITS
t int dee orough
Improvement arcnotintended earared pletio.If, owner-pdder ill haveng or
Improvement b sold within one yearo(compialon, tbeowner-bunderwlll)uve
TOTAL:
(e rden of proving that he did not bunimproveaf
d or for purpose sak.).
L as owner of the property, am exclusively =trading with licensed
contractors to construct the project(Sec. 7044, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Cmdr cto'. License law does nd apply to ao owner of property whoALTER-DRAW
bunds or improves thereon, and who contracts for such plojects with a
cryLI[adoKs) IicensM pursuant to the Contractor's License Law.
LJ1 am exempt under Sec. B k P C for this reason
k VENT -WATER (FA)
_ BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE F
DRAINS FLOOR ROOF' AREA, ��'
FIXTURES I'FR TRAP
SANITARY Y_ N
RECEIPT #
Owner Dae
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have it certificate of consent to y ora
SCIi00L TAX Y N_
o( o theure,
certificate WorEer%Compemationlreurance era certified copy thereof (Sec.
3800, lab CJ
RECEl7'T #
GAS EA.SYSIFAt-1 INCA 0I1'IT.E7S
PARK FEE Y N
Policy
RECEIPT M
ComCan Y
GAS EA. SYS'T'EM -OVER 4 (EA)
BUILDDINGINGDDI V 1510\ FEESen1(led
copy is hereby famished.
MCcrtlRed ropy is filed with the city Inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
(This section need not be compiled lithe permit Isforone hundred dollars
C
($100)orlese.)
I cent that emin ploy an person In an tmannerhe work An As t become
1 shag not employ any person In any manner ro as to become subject to the
Ibjrcit 1. Iso the
W Applicant Compensatlon Laws of California.
lifornla. Date
Applicant
after m'Co this Carl proo(FsempteLyou
NOTICETO APl'Lyed to
should become subject it the Workers Comperuatiw provisioru of the Labor
Code, you mus forthwith comply with such provisions orchis permit shall be
deer,ea revoked.
PAID -
Date Rccei t#
I EWERS$ ARY STORM FA mOFI, /•1
l
WATER BEATER W/VENT/ELECTR
ENERGYFEE Y N
pAlp
Date Rett's t#
ATER SYSTEM/TREATING
NEW RESIDENTIAL PLMe. SQ}7.
TOTAL:
BUILDING 'E
T
CONSTRUCTION LENDING AGENCY
Ihembyaffirm that there is a construction lending agency for the perform
ance of the work for which this permit Is Issued (Sec. 3097, Civ. Q
SEISMIC FEE
ELECTRIC FEE
iMac`. Name
Tenser. Aaarm
I certilythat I havereadthis epplicationana statethat theabove Information
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
ecrred.lagreeto comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the abovsmentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
Against liabilities, judgments,coasand expenses which may le.cy wayacdue
against mid City in co quence ofthe ¢gatingof Wspermit.
s
PERMIT ISSUANCE
ALTERORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
FEES PAID:
Dale Receipt#
SUBTOTAL:—
AIR HANDLING UNIT (OVER I0,000CTTO
CONSTRUCTION TAX
Slgruture 5fAppBrant/Contractor J — Date
IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS LOSURE
HFATING UNIT (TO 100,000 BTIp
Will the applicant or future building occupant s e or handle hazardous
material ate defined by the Cupertino Municipal Code, Chapter 9.12, and the
I katth and Suety Cade Section 255320)7
Yea Ii No
Date Recel t#
HEATING UNIT (OVER 100,000 BTU)
IOTA
Will the applicant or future building occupant use equipment or devices
which emit haeardous air contmhunt as drilled by the Bay Area Air
Quality Management District?
Yes 1j�j No
havercad Healthe h
Safety25SntundcrChapter 6.95 of
ats Code, Sections
' the erstand t at fifth bSafetyCode, et Curr ntly have
33 ateand 255at it
that It troy
rapureibs the
.p.ruzndtM1at no By
ce notify the occupant of the rcqulrcnrnts which must be met
nupant not enentiyns,rds which
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
'r51 h h rD
V' W V SJ
SEP 1 1992
BOILER -COMP QHP OR IWDM BTU)
BOILER- COMP (OVER IDJ,000 BTI])
NEW RESIDENTIAL MECH. SQ.FT.
d
a
prior to issuance of a Certificate of Occupancy.
TY Ur %,urcnluvv
ISS Vl/C✓
Owner or authorized agent Date
TOTAL:
OFFICE COPY
u, r., r •�•. .. `.( v «. _ w�� 'm—.. a R¢e rnV + rq+.r.l _ } :N. ..,.
3 .1..
PERMIT p-5264
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.O.S./P.M./Tract No. Lot No.
A.P.N.: Books 2. (i Page Z.3 Parcel 0 3 41
Property Owner: Ca ro I (,)Duda r CL
Mailing Address: `� 1 Z$ -50 n le- rn I I I � h
(If different) 54,,r 4v c� SO "J U
Telephone:
Sirs:
(I/ We), being the owner(s) (owner's agent),
/0?20 �,-mire
Date 5-ew re "I lL e r D) 1997-
make
99Z
make application for connection of the property at:
VeP
no
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family ;`< ; Multiple Family ; No. Units
Commercial , Industriall; 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 4t'- r of t/v �ti`N 'Pf h D Building Department 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 (that portion of the sewer within the street right-of-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� , $/mo. x / 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:P✓ti
Owner's Agent:
(print name)
Receipt of $ MV acknowledged and permit granted.
MARK THOMAS &&COO., INC., District Manager -Engineer •
by
Note: See See Details on other side of this permit.