22645 (2) _ APRLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prated Identification 1' 14T 22645
Building Addrns:
Zia � G,v�de� yard Gov
A
GO:J ate. one:2 SS 6 97 L CITY OF CUPERTINO-BUILDING DIVISION
• c a Nj c: Co. s• NG
Lm No APPLICATION /PERMIT
NI-7
� B=IELDC-M A MP BINGMECHAIXAL CATEGORY CONTROL I
rahBee/Fsgimer. Lk.No:
,�// J�/ Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addnes�Or/�C 70 .ts.,,-Q•a. c,e PFRMITISSUANCE •
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am lktownt.nder pravWomof Clupter 9(commenc AITLIANCES4?1E4DEM7AL JOB DESCRIPTION
ingwlth Section7000)of Dlddm3 otthe Buslreswd PmfevlonsCode,and my
Ikons la In full farm and effect. PANELS
LI¢nxC - Z is
ont,1 ��� O�
Date Crador
ARCHITECTS DECLARATION 201-1000A1,IPS
re I undenataM my plans shall be uaed as publlc record& OVER 10DO MAPS SQ.FT.FLOOR AREA
O
�j Lumned professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECULCIRCUITLB
MC
l hereby affirm thatI am exempt fmmthe Contractors License law fa the /
folbwing rtasm.(Section 70115.Busines aM Pmfesbns CMC.My dty or
O qZl 712dP.ME1'FR OR POLE MSf.
rr,� countywAkh requlreaperWttomnstrugakar,improve,demoWh,orrtpdr
a nysbuctumpdatoltabsuancx,alsorequbv LheappB¢ntfawchpe tto POWER DEVTCES
ya I file a sigaM statement that he at lammed parsuant to the provbbv of the
O� Contactor's License Law(Clupter9(commencing wHhSection 9WO)otDM.
1,,,3 sbn3ofthe Rusmess.dP runs Code)mthat hebeumpt thertfiomaM ''WAIA9NG POOL F]ECTWC VALUATION
Sn the basis for the alleged exemption. My violation of Section 76115 by any,
Gi
applicant far.pomdt wbjeds theappikant to•civil panshy of not momthsa OUTLE[SSWHCHES-F1XfURES
five hundred dollars($500).
�j F1 I,as owner of the property,or my employees wuh wages as their sale NEW RESIDENTIAL aXCIR SQFT. STORIES TYPE CONSTRLCT)ON
�/� campewHon,w111doNe kmdtheatru=mrt6 WeMe or offertdfor
p sale eiae]0K Biulnas and Pra(esbns Cade:The Contractors License Law
does roue apply to an owner of property wha builds or improv.Ihe.,and - OCC.GROUP RF5.UNITS
who dorswchworkhm xalf&through hisownempleyes,provided that sacs
Improvemaw are nlRt lntmded oroOerM for Bale.ILhowe¢r,thebulldingcr TOTAL: -
tmprove mbwdw hlnomyearofcompldlb theowner- Werwgilove
tI�s�urdm of pmving that h<did notbuuaorlmpm,etorpurposeafu6.). QTy. PLUMBING PERMIT FEE
LJ L as owner of the property,am eacbslwly contacting with licensed FLOOD IDNE- APN
ontractan to construe the project(Sm 70K Bushes and Pmfesbs Code: P 17 ISSUANCE
D
The Gmtado/s License,Law dao nae apply to an owner of property who ALTER-DRAW 4 VENT-WATER(EA)
W Ods ar I.P.thereon,aM who mndne)(a suchp(ojem wbh
gn4acta(s)licensed pursuant to the Cmtnea/s License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ ve
I am exempt under Sec B k P C for this manFFrc
Avner Dale DRAINS 11D0R ROOF,AREA,COND. SANITARY Y_ N
RECEIPT I
WORKMAN COMPOVSATION DECLARATION FIX'DJItF_S PER TRAP SCid00l,TAX Y_ N_
❑f hereby affirm that I have 1 certificate&am d b fftheure,or. RECEIPT'I
3WOL e&Worker'Comperuatiminwnn¢¢•¢rtlfled copythertol(Scc. GAS F.A.SYSfEh lwGt OUTLETS � PARK FEE Y N
RECE38011,Lab CJ
Pd4yI Z G/G — / GAS EA.SY917EM-OVER/(EA) DING DIV
Ca v � BUILDING DIVISION FF.E9
Icc�rtln! mpy6nertlry rurwned: exr lsE/wouslRL was1E INTERCEPTOR
PLANCHECK FEE
Certified copy b filed with the city Inspection didsim.
CERTIFICATE OF EXINI MON FROM WORK ERS' CREASE TRAIa PAID
COMPENSATION INSURANCE SEWER-SA�ARYSroRM EA 2(aWT. Date Recel t#
(Thlssectbn need not he completed if the permR 6 fa am hundred dollar .DO
($ero)ar live.) WATER HEATER W/VENT/F]ECTR ENERGY FEE Y_ N
I mrtuy that N the pedorwnce of the wok forwhlch this pertrat 66wed,
I shall nae employ any Person In any manner w as to became subject to the WATQi SYSTEM/TREATING
Wak.'Comnsu,.
plaHonlaaf Cahfomh. Date PAID
APP liant
Z p Noncero Al>t't.ICANT:u,,Ber rnswngthb certulate of F;nemptwn,you NEW RESIDENTIAL PLMB. SQFT. Date Revel t# '
should became,subject to the Workers s
Compeation pro isbns&the Labor TOTAL-
CC N Code,you mostf¢thwdh mm ply with wcA provbbns orthla permit shall be
> deemed invoked. //��
W O CONSTRICTION LENDING AGENCY k/f ISMIC FEE
Q. I hemby afBmn that them b s mruM
mtctlm leing agencyfor the pedorm ELECTRIC FEE
Zace of the work far which this permit b loved eSec.3097,Civ.C.) TOTAL-V O IeMu's Name - PLUMBING FEE "v
LL H leader's Addreo QTY. MECHANICAL PERMIT FEE MECHANICAL FEEO W I¢rtitythatl Hveread lhbsppllcetbnaM sat<that theaboveln(RmsOm
S bconcct.lagrteto comply wdh all dtyaM muntyordlnan¢-s and eUte laws PERMIT ISSUANCE FEES PAID:
>- mlatingtobulldingmmlruelm,aM herebyauthoAunepnaentatNs»ofthis i
F N citytoenterupon theabove-mentloned property faimpaction purpoaes ALIFRORADDTOMECH. -
(We)agrea to sve,Indemnify an d keep harmless the City of Cupertino Date Reeei t#
V
against llabNtb,Judgments, ..M expenses which may to any way accrue AIR HANDLING UNIT(TO 10.=CFW SUBTOTAL: 11
.ga acuy eine of she LvaabR&wapem,B. AIR HANDLING UNIT(OVFR Io,00o CFM) CONSTRUCTION TAX '
~fAppuant/Crntrae� Dam FXITAUSTHODD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building oaapant atom or handle hafardous HEATING UNIT(ID 100,000 BM Date Recei I#
material a dcflmd by the Cupertino Mu Ndpal CMe,Chapter 9.1;and the
Health and Sfrty Coda Sl imt ZSSn(a)t HFAMG UNIT(OVER 100,000 RM TOTAL:
g !
Ya No _
WtheapplbNm turebuildingoccapantuseequlparent ordevkrs VENTILATION FAN RES'D) ISSUAN _
which eMt hara Haus air cantantlnarm a de0nod by the Bay Arta Mr Quality YMuagemerrc IXarkt'! BORER-COMP PFB'OR100,IXO BTU) �s awl
4 You r2 No !!y (I V r
havrmadlheh cot matedabrt..25-'enbunder Chapte , I of BOILER-COMP(OVFR 1W,000 BTU)
u Glifom6 HeathebutletyCMq Sectbns7tlyha]SiVwdt,that I
rMenwMyI.meff building dors of the rrequirements
quire encs tenantmost it man NEW RESIDENTIAL MECH. SQF7
responsibility to notltythe acata I dthe
pancy. mmeNewhk-h neral be met
prior to!assn¢&a Certlfl¢tc olOavparry.
Owmr ar authar zed agent Dale TOTAL ISSUED BY:.
OFFICE COPY
SEWER CONNECTION PERMIT SERIALNO. Pj" 1 5 1 7 8
®UPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No../5- Lot No..,3 .9
20065 Stevens Creek Blvd. A.P.N. Bk....� ..... Pg....�g.... Par..2
Building C
Cupertino, California 95014
Phone (408) 253-7071 Date...e�e.-- ..7�.....!� ............ 199 .
The undersigned,being the owner(or owner's agent)of the property located at .... �. .3....<-57 !/!...kJ.....
....................
consisting of the following TYPE OF BUILDING:
Residential: Single family.. .... Multiple............ No. Units............
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 .....Cil.���.... ?1... �l1I' !H.Q,,,,,,,,,,,,,,,,,,, BuildingDepart-
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... !�....0/a!t?'...� ! .��/A.!t/. Telephone�dl... .s�� ���� ...............
" -
Mailing address if
differentfrom above.........I_ ................................. ......Tj...... .....................�....]....................
By' 4N..... .......tZl t? ...... . .............
A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above
property.(Note—See Detail I)
FEES:
Connection Permit Fee
Sewer Service charges to June 30, 19.?'Z.., ........./mo. X.//..mo.
Inspection Fee for backflow protection device
TOTAL $ 9
Sa
Receipt of$.l,�J7,......, acknowledged and permit granted. . MARK THOMAS&CO. INC., District Manager-Engineer
NOTE.•See Details on other side of this permit
CUPERTINO SANITARY DISTRICT
� I
NOTES: All valves Iq be accessible and maintained M Property Owner.
Overflow point at least Welve in0es02"1 below laweet finished
floor containing I.b,,.
Kelly Valve Imtaled At Prapesty Line to be readily removable
for Lateral Sewer maintenance.
£ I
FIFI Level
"
Kelly Valve FlnIeM1 Floor Level
Flnien Grade {
Keay Valve —E LL
�( g
Wive Acceu x —/
with Vetoed C6er - Valve Access Bon ' E
Backwater Valve '
FF.
Figure Figure 2 Flour. 3
Kelly Valve- Beta. Surface Backwater Valve—Normally Kelly VaNe-Above Ground
Inslallolion-Shown at required installed at shallowest point Imtnllall0n-Shown installed •
Property Line Clemiwl. along House Sewer between Close 10 Wilding.
Property Line and building.
DETAIL
STANDARD BACKFLOW PROTECTIVE DEVICE INSTALLATION I
Distance from 0 la be As
data as wacticabee.
J
Removable Cleanwt Plug
A. Flnish Grad-
' Wye fa. Riser
Sewer Cleanout Bos with LIG to be accesSiple
Dmaintained by property owner.
SM1ort length Riserer Pipe
Adaptor coupling 1/8 Bend
FLOW v
Ho a Sew
L of 5L S
E:°FATMnimum Ila" Mtermiby Building DepartmeN.
�Laleral SewCleanoutt to
to b• some
size aS Lateral Sewer. •
DETAIL
STANDARD CLEANOUT FOR LATERAL SEWER J