25201 (2) APPLICANT TO FILL IN INSORMA:ION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINOT-FLS PERMITNQ. ^O
1
APPLICATION/PERMIT 1'LU,MBING-MECNAN'CAI, L
BUILDING DIVISION BUILDING PROJECT IDENT[FICA'1'[ON
BUILDING ADDRESS: ar / SANDARYNO. API'LlCo,LON SURMf1'1'AL DA'IR
D ///t/ . ONrf a LOI a C-nrg3
O E: a �N CONTRACTOR'S NAME: LIC NO:
NIC CONfROI.a
RCHI QINEV LIC NO: ADDRESS: ❑
CONTACT: PHONE:
2 QTY. ELECTRIC PERMIT FEE
g BU
ILDING PERMIT INFO
l / / /O PERMIT ISSUANCE BLDG ELECT PLUMB MLCH
LICENSED COME RACE DECLA]ATIONE1F-1ElAPPLIANCES-RESIDENTIAL JOB Dl!SCRIFTION
pC2 Thereby off i that am Iittnxd under provisoonsofCTap¢r9(commencing with
+100 "it fore—and, Divisiun3 of the Business and Professions Code.and my license is in PANELS
Y F. full farce unJ c t.
Fzw Litt t ec Li<.a UP T02o0AMP5 V\air'
way 1 Contractor 201-In00AMP5 I
7 FO,G A CHITHCTS DECLARATION OVER 1000 ANTS 1 "SQi PI'FLO S/SQ.PT.
O Z_C 1 u demand my plans shall be used u public records.
W SIGNS ELECTRICAL
w J JER
Cyj Licensed Professional
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
UI herehy from but 1 wr exempt from the Contractor's License Law for the
yFo following reason.(Section 7031.5.Business and Professions Code:Any city or county TEMP.METER OR POLE INST. DATE
w which requires a permit to construct,alter,improve,demolish,of repair any eweturt
ce W�2 prior o its issuance,also requires the applicant forsuch permit to file a signed sntemrnt POWER DEVICES
w w<O dust he is heated pursuant to Ne provisions of the Contractors Lt..law Inceptor
aaopC 9(commencing with Section 7")of Division 3 ofthe Business and Professions Code) SWIMMING POOL ELECTRIC VALUATION
,`2, or that he is exempt herefrom and the basisfor the alleged exemption.Any violation of OUTLETS-SWITCFIFS-FIXTURES
L Z 4 Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
nmetore than five hundred dollars($500).
KFp ❑ 1.rsowneroOhepropeny,ormyemployeeswilhwMeaastheirsolewmpensatiw, NEW RESIDENTIAL ELECTR _SQ.PI'. STORIES TYPECONS'1'RUCI'ION
cc O, willdmthe work,and thesw<sum isnot intcndcdorofPored for sale(Sec.7t1a4,Bus
and Professions Code:The Contractor's License Law does not apply to an owner of
propcnywhobuildsor imptovcsthcmon.andwhodoessuch work himselfordtrough his
ountamployces,provided that such impnvcmcntsamnotintcndedorofrcrcd fmsala If. OCC.GROUP RES.UNITS
however,the building or improvement is sold within one year of completion,the owner- TO fAL:
builder will have the burden of proving that he did act build of improve for purposes or
talc.).
❑ 1. ro%nerofthe noeny.amcxclusivelyconimctingwimliccnsedeontractoms. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
onstrua the project(Sec.70o14,Business and Professions Code:)The Contractor's
License Law does not apply to an o,stow.Property wholbuilds crlmproveat come.and PERMIT ISSUANCE
whmcomncus for such projects with a comtamur(s)licensed pursuanno Ne Conlmctor's se Law.
License
ALTER DRAIN&VENT-WATER(FA) FEE SUMMARY
❑ i wn exempt under Sec. .B&P C for this naso°n BACK FLOW PROTECT'.DEVICE '1lS1DE 71-5
SANITARY Y N
Owner Date RECEIFP#
DRAINS FLOOR,ROOF,AREA,COND.
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y
(:I cn'C,, affirmthall havesem irca¢ad O.py,hc.f ce,391or.Lab C.) hicke of Fl%TURES-P[R TRAP RECEIPTp
Workers'Compenaaionlnsurance oracenificd copy thereof(Sec.3800,Lab C.)which PARK PEE YN
emallemPby 'sunde his pertnif GAS-G.SYSTIiM-1 INC.40UTLETS NECEIPfN
Me BUILDING DIVISION FEES
pant GAS-LA.SYSTEM OVER 4(EA) PLANCIIECK FEE
❑ Cenifed copy is emby fait/,hal
❑ Ccnifiedcopyid filM ani the city inspection division. GREASEffNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION MOM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Mosscnion raced not becomplcted ifflepermit is for one hundred dollars(SIM) IiWF.R-SA 1'ARY-Sl'ORM EA.2IXIFT. ENERGY FEE
or less.)
I certify that in the performer.of the work fear which Nis permit is issuet,Ishwi WATER HFATER W/VENT/ELECIR
not employ any person in any m as to became subject to Ne Workers PAID
Compereationlawsof Califomia. Date u WATER SYSTEINI BEATING Dae Reccipsa
z z Applicant
O N0I10E TO APPLICANT:IL after making this Certificate of Exem should NEW RESIDENTIALPLMB. SQ.FT.
ptio de,you ou TOTAL:
I�- CO becomcmomply it Workers Compemetiis prmisiomofthe Labor Code, most
> forthwith comply with such provision onM1is pertnitshali be deemed revoked. BUILDING IEEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
z I hereby affirm thatthem is a construction Lending agency for the performance of
The work for which this permit is issued(Sec.3097.Civ.C.) LECTRIC FEE
V O Lenders Name
Lt. U lender a Address QTY. NIECE IANICAL PERM IT WEE PLUMBING FEE
U 1 certify that 1 have read this application and site that the above information is MECHANICAL ME
r1^ Pa correct.l agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
F" buildingeommuction,and hereby authrrife mpreuntative,ofthis city center upon the CONSTRUCTION TAX
V Z movomemianedp ray faro tiro purported. ALTER OR ADD TO MECH.
(We)agree Jc n'y' d keep harmless tM1c City of Cupenin.against
Iiabilifies,jud cost whi y in any wayaacrue against said City AIR HANDLING UNIT(010,000 CFM)
in man the T
AIR HANDLING UNIT(OVER 10.000 CFM)
out Applicnn oneaor Date EXHAUST HOOD(W/DUCT) PAID
R
HAZARDOUS MATERIALS DISCLOSUE
HEATING UNIT(TO IW,WO BTU) Date Receipts
Will thenpplleant or how,hoildingom,,mt dome,handle hazardous mutenal HEATING UNIT(OVER 100.(X10 BTU) AL:
a,defined by the Cupertino Municipal Code,Chapter 9.12,and the[lath and Safety
Code,Section 25532(a)T
❑No VENTILATION FAN(SINGLE RESIDE
CI Yes
ISSUANCE DATE
Will thea liventorfumre building occupant torleviees whichemit BOILER-COMP DHP OR 100.000 BTU)
pp gby the qea Air
anNaus air rnntaminante as;defined by the Bay Arca Air Quality Management pO1LER-COMP(OV13R IW,IXgBTU) P A D
ittrictT
m ❑Yee ❑No NEW RESIDENTIAL MUCH, SQ.FT. n1
1 have mad the havmdoua materials requirements under Chapter 6.95 of the cJUev 15 1993
Calil'omia Health A Safety Code,Sections 25505,25533 and 25534. 1 understand that
if the building does not currently have a famous.Was it is my responsibility to notify the
aooavant art me rewtrememt wren moa rte met prfear m iatmana art a eenifioate art CS I Y Ur QUrGt1 I m
OccupnramhorizeA agem Dole TOTAL: ISSUED BY:
_ .... ... .- n.^,a - .. .. , .p.�etr,�„' . .,... ,.y. ;y+..y.�..rw l^+.yv.9,.n w w ..q•.. n('�M >, rc,prv, rr✓+«t rn�•' ..�.,.J.. rr ....,r ^'b'-`.+ r ... .. .
PERMIT P-15304
iW
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. 3 D Lot No. 10 I
A.P.N.: Book �(0 PageOfe
_I Parcel d 41 Date V JV7
I>
�
Property Owner: >e-V�,`i ' "� r ,cl�� ✓V) -
Mailing Address:
(If different)
Telephone: 3 7 11,
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
/009
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family�_; Multiple Family ; No. Units
Commercial , Industrial ; Other ; No. Units
do hereby request a permit to connect to the sewer system of the Cupertino Sanitary District.
yIN 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 of 6-P Building.Department and obtain
inspection and approval by said Building Department prior to covering ol 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:
6`c
Connection Permit Fee: $ 2 (d
Sewer Service charges to June 30, 19-9--S , $--4=— /MO.x mo.: $
0
Inspection Fee for backflow protection device: $ S
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:
Owner's Agent: 1A1 ll-e� 0 4V'b $ , 7)RA /
(print name) A3 L Ej/7YfG
Receipt of$ 2 acknowledged and permit granted. -r,_.. Vc"'
MARK THOMAS &CO., INC., District Manager-Engineer
by:
Note:See Details on other side of this permit.
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be OS close as practicable,
da not to exceed five(5) feet.
J
`w Removable Cleanout Plug
n
0
a Finish Grade
Wye for Riser
Sewer- Cleanout_ Boa_ with--Lid to_be accessible
and maintained by property owner.
Short length Riser Pipe
Adaptor coupling 1/8 Bend
��- - FLOW m
Lateral Sewer House Sewer
Lateral Sewer slope House Sewer slope
determined by District determined by building department
=CLEANOUT TO BE SAME SIZE AS LATERAL SEWER— e
Notes:
1. Distance from the property line not to exceed five (S')feet.
2. Property 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 duri,di,lional R.mmtlon,
Accepted By All duri,dicrons
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade Installed Below Grade Installed Above Grade
Shown Between Street Right-ofway and Building Shown At Property Line Cleaneul Shown Adlot..'To Building
Requires Regular MaintehanCe w Requires Minimum MairronanCe Requires Minimum Maintenance
Valve To Be Removable Valve should Be Removable
VALVE ACCESS BOX FINISH FLOOR
wnvvem.a Ccvr
A.
Level at FINISH FLOOR KELLY VALVE
A. t
al
VALVE ACCESS BO% Eit
IFinish GradeFIn,,h Grade
E
BACKWATER
VALVE '
FLOW l? wor 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.