22428 (2) ` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERMIT
Building Add. NO.
I%3(as GAAcj L),'c,,) 22428
Owner'.Name: Phone: .
w�h; - N ki4 255— 304.0 CITY OF CUPERTINO-BUILDINGDIVISION / _�/
C DJJ—:ea 5r pA/ (�� c.N. APPLICATION / PERMIT '6
1`�AG a BUILDINGELD7 MCAL PLUMBINGMFL:I IANKAL CA=RY CONTROL♦
Architect/Engineer. Lie No:
4 ELECFRIC PERMIT FEE BUILDING PERMIT INFO
Addeo. .0. cep :701 CES
PFRMITISBUANCE ❑ ❑by.iff ❑
LICENSED CONTRACTOR'S DECLARATION JV
I heh SectIoir70 thafDiv Ocrosedunderpessard ProChapter (cornrnrn APPLIANC6RESIDEN['fAL BDF_SLRQTION
Ingwith Scdion7o00)of Dlvidon3dthe BudressandProfesalmmCade,and my '
licemeinln fo and effe"t I Op N PANPIS /N / I
Lkeve C Lie I DD IJP--'1 L R![l\ lsem�)e V
Date:Z_M / ContractorUP TO 2DO ANV5
ARCHITECTS DECLARATION -1 'CHIN'
,4z I undersand my phm shag W used u public rtmds OVER 1 ODD AMPS SQ.Fr.FLoog AREA S/SQ.Fr.
L U Lkenaed Professional _ SIGNS EXC RICAL o 0-0 E D I N `
6 OWNER-BUILDER DECLARATION SI'TCIALCIRCUIT/MiSC 6V1 P E R
, � Thereby afRrmthatlamexemplfrom the Cordractorb LlmveLaw for the 1V,
Z7
pp folbwing rtawn.[SMIa170315,Buslneo and Pro(essbv Code:Any ctty or
F Z H IFl✓3.METER OR POLE INST. ,
<4Q muntywhid requkaapermdtommtvd,titer,knprove,dmnlbh,or rrpalr
K anya signs a statement
Is shore d pursuant
to the
rmislo pemdt a POWER DEVICESC.n - j/ g '
C I file a mor'.ratement Ihrt he b Banned sing it tSe provldom of the
Dµ sum 3 oftoeItualLlc�me lnw(Chaptm9(mm)orthat with Seabnhe4Tom anal
elCn3o(the BuWmandPMmbm Code)orthn heberempt lherefromand SWUIMINCFWI.fl.9,7111IC �.
_ the Weis for the alleged eaemptimr. My violation of Section MIS by any OUTH.EISSWITC1iESF1XT[JRES
0� •ppha tforapemrtaubjedstheappkc ttoadvllpemhydnmm mtlun
IT, undred dollars(SW. SQ.Fr, STORIES TYPECONSTRUCTION
k < 1,ams owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELCCTR
compeation,willdothe work andthe structure is not Intended or offered for
$ ❑ sale(See 7064,Buidessand ProfessionsCode:The Contractor'.License Taw
�s8 does not apply to an owner d property who builds or lmpmwes themes,and OCC.CROIIP RES.UNITS
whodoessuchwork1u.1f orthrough hbown employees,prwlded thatsuch
Improvements are not Intended or offered for Bale.If,hwvever,the W IM Ing or TOTAL
Improvement issold within oreyeardcompinion,the owner-builderwW have
t4Lkunien of proving that he did cot build or improve for purpose of sale). QTY. - PLUMBING PERMIT FEE -
"I,as owner of the property,am ea<huWm
ely ntraetbg with Boeneed FLOOD ZONE APN
cormetcas to construct the project(Sm 7066,Busies and Professions Cade: PERMIT ISSUANCE ('�
The Contractors License Law does not apply to an owner of property who ALTERDRAIN k VENT-WATER(FA)
-
W lds or improves theeon, and who cont.. for such p(ojects whh . - FEE SUMMARY
cgW4+ctor(s)licensed pumunt to the Cmtractw: m LkzLaw. gApI FLOW PROTECT.DEVICE
i_J I am exempt under Sec B 6 P C for this reason
Owner Date
DRAINS FLOOR ROOF,AREA GOND. SANITARY Y_ N_
WORKMAN COMPENSATION DECIARATION RECER'T
K
❑I hereaffirm that 1 have a certificate of cement to self-Nsum,or �FS'PER TRAP SCHOOL TAX Y_ N_
by RECEIPT I'
mrti0am of Workeri Compemnimr lwnna or a certified copy thereo((See GAS EA.SYS7EMI ACA OU17.EIS PARK FEE Y N
RECEIPTa—
I'd Y GAS EA.SYSTEM-OVER BDILDING DI VIS ION F¢FS
relied copy b
Certified copy is(Bed witthh the
heebytlty inspect division.M. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
he
CERTIFICATE OF F)cEAfPTION FROM WORKERS CREA''�TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARYSTORM EA 2'lOFr. —D—ate Recei t71
(Thbsectlonneednabecanpleted Utk permit lafmane hundnddoBan I
($100)aless.) WATER HEATER W/VENT/ ENERGY FEE Y N
ELECIR
I armythat In the pelcmn caofthework forwheh Ws permit is hued,
I mail nm employ my person In any nu nner so as to become object to the WATER SYSTEM/.IRFA.IING
WCrkery Compe.k,.Taws.(Callfanla.Date PAID
Applicant NEW RESIDENTIAL I'LMfB. SQ.FT, Date Recei tM
Z NOTICE TO APPLICANT-.If,after making this Certificate d Exemption,you
Fshould become subject to the Workers'Copeawbm
tion prlsofthe Labor TOTAL:
WN mmCode,you Bort forthwith comply with such provbiovor this pendtshallW BUILDING FEE
] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffrro'hat then b acovtruction krulingagency forthe perform ELECTRIC FEE
Z ance of the work(or which this Nrontb laved bee 30Y7,Civ.C.) TOTAL: —�7
U O lender'-Name PLUMBING FEE
LL F- Iendec.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l certify thrtl have mad thisappllationand mtethat the above Informant
W Ismrrtd.I:gree to cmnply wkh.B etymal muntyoNinm¢s and sate law- PFRMITL%UANCE FEES PAID:
rt ingtobulldingmmtmdim,aMkmbyauthw mpmenUtiveafthb
U) city to enter upon theahovcrmntiored property far WpeNon purpose. ALTER OR OR ADD TO MECH. Date Recei t#
(We).gree to save,Indcmrdfy an d keep harrtdess the City of Cu penes SUBTOTAL:
V against lubbmnd vn
iBt ,�udg nt-, s-ae.pewhich may in my way aceAI
s R HANDLING UNIT(TO 10,000 CFM)
agel dCity in ae9° of the granting of this permR.
- A� AIR HANDLING UNIT(OVER t0,W0CFM) CONSTRUCTION TAX
(r "'
Date FA7IAUST HOOD(W/DUC(W/DUCT) CONSTRUCTION TAX PAID:
HAZA RDOUSOUB
g re of pp m AU MATERIALS DISCLOSURE
Wil the spinant orby theC p rtIroiM udp.1 Code, Chapter le havrdthe HEATING UNIT(TO lm,caDBM Date Recei tN
- litaltalas Safety odeSCupertlm MuNtlpal Cade,Chapter 9.13,and the
H F-1 Yes
Safety Code Sedlon 7ri533 W t HEATING UNIT(OVER 100,000 BTI1) TOTAL:
�Ya No
WWthemit hannicda turebu0dbg ac-fine use tNu he
Ace,
Al, s VFMIIATIONFAN(SINGLE Rp9D) ISSUANCE DATE
which emitW emeMsairrict? meas dcRrmd bytM Bay Area Air ar
�Iby Nuvgement lXstdct7 BOILER-COMPPFR'OR1W,IXq BTU) Pima
Yn ❑No
W ve read t Health
&dov rt oriel,S ctic remrnb u 3 and 2pter 6.95 of BOR.FR-COMP(OVER 1 W,ODO BTU)
i the Gllfomta Health he building
Cade,nca.m tIyh ve.m. t tt,,t.T
underat,ndthat
tonctilytheongdoes nothe reentiyhavea hick that it met NEW RF9DFNTlAL MECH. SQ.F7
respovBoBityto malty the aapnt d the raquirtmem-whioh moat be net -
prfertofsaumceda Certl(iateo(Omopanry. CW of.ras�...a[__
Ownoraauthmtu agent Date TOTAL: ISSUEDBY: `ar- =jM)A O
OFFICE COPY
_2112
/3 SERIAL 2
SEWER CONNECTION PERMIT NO. P ` t,; 15146
WUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No..I� 7?P.. Lot No...Z.0....
20065 Stevens Creek Blvd. / A.P.N. Bk._;FZ�t ...... Pg.../.?.... Par. 2.y��..
Building C j
Cupertino, California 95014 I /
Phone (406) 253-7071 / Date... ��'............. �............. 19
The undersigned, being the owner(or owner's agent)of the property located at .... (fail /�/�GCJ
P ......4�—�•, . ..................................................................................I........,
consisting of the following TYPE OF BUILDING:
Residential: Singlefamily....>".. Multiple............ No. Units............
�.F_.._
Commercial............ Industrial............ Other............ No. Units.............
d reby 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)andto 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)
/Ir
3) To acquire a permit from the ..... 7(/1D.. ................... Buildirig-D"epart-
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..�??,;7. ........... Telephone� S 1...2.5 :. �G a
.......................
Mailing address if
differentfrom above............ ............................................................................................
i�`i l� r. (� r
A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above
property.(Note—See Detail/)
FEES:
Connection Permit Fee
Sewer Service charges to June 30, 19.,?./. $.......`......./mo. x.$mo.
/ �V-
Inspection Fee for backflow protection device
TOTAL $ 2'
Receipt of$. 'f..�o.... acknowledged and permit granted. MARK THOMAS &CO. IN/C., District Manager-Engineer
'�t _ _ NOTE.See Details onother side of this permit"
CUPERT/NO SANITARY DISTRICT
�t
NOTES: All valves to be accessible and maintained by Property Owner.
Overflow point at least twelve inches(12") below lowest finished
floor containing plumbing.
Kelly Valve Installed at Property Line to be readily removable
for Lateral Sewer maintenance.
g
J
°' ry FI Level F�
d E Kally Valve Finish Floor Level B
Finish Gradesee 54
Kelt' Valve E
Valve Access 3
with Vemed C �r E Valve Access B. EE
Bockwatr Valve
FLOW
Figure I Figure 2 Figure 3
' Kelly Valve- Below Surface Backwater Volvo—Normally Kelt' Valve-Above G:mlbd
Irmtallation-Shown at rewired installed pt shallowest point Infinllatlon-Shown installed
Property Line Cleanout. along House Sewer between close to Width,PropertyUnitand b between
STANDARD BACKFLOW .PROTECTIVE DEVICE INSTALDETAIL
LATION I
Distance from 0 to be as
corse m practicable.
o
Removable Gleanand Plug
o. Finish Oracle
Wye far Riser p•
Sewer Cleonwt Bo. with Lid to be ....11ale
Star, length \ and maintained by property owner.
Riser pipe
Adaptor coupllnR I/B Bend
FLOW
w Lateral Sewer I Han. Sews
TE nimum slope determined by Building Department.
'Lateral Sewer Cosanout to be some
size a. Lateral Sewer.
DETAIL
STANDARD CLEANOUT FOR LATERAL SEWER J
l