27233 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ICAI. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING BUILDING
BUILDING PROJECTIDEN`1'[FICA'1'[ON 27233
F-,ILDING ADDRESS E
1: ^ SANITARY NO. APPLICATION SUBMITTAL DAT
e f, W _fyr�)%rQWV % UNIT LOT
OAMIi: a CO C" N
W E SNLICNO: 'V �•
N/C CONTROI.p
CIIIIECf/IiNGINE . LIC NO: ADDRESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT EEE BUILDING PERMIT INFO
BLDG ELECT U MECH
PERMIT ISSUANCE ❑ ❑ XK
LICENSED CONTRACT'OR'S DECLARA'T'ION APPLIANCES-RESIDENTIAL
pyz, I herebyafftrm Jul l am licensed under pnovisionsofC'hapter9(commeneingwith JOB DIS MIO
rco[ Section 7000)of Division 3of,he Business amkProfeasions Qpde,and my license is in PANELS
aUU IUllfora and effect.
QFZyl Liana Class Lic.# UP T0200AMPS IA
L,¢c- Daft Contractor 201-1000 AMPS �-�O
ZQNZ ARCIIII'ECTS DECLARATION SQ.FT.FLOOR AREA S/SQ.F!.
OZ—❑
1 understand my plans shall be used as public tecools. OVER 1000 AMPS
F.,y F W SIGNS ELECTRICAL
Licensed ProPoasionul
2-Lowu OWNER-exempt from
m the CoATION SPECIAL CIRCUIT/MISC.
Sd5�OyU I hereby affirmSe that 131.exempt Pram the Contractor's c:A.,i Lew for the s
pJ3my whichngrcana erten to 7031.5.constrct.a sec and Rvfessiona Code:Anycity or counry TEMP.METIER OR POLE INST. I " 0 n T77,
8
L-��; which rcyuiren a permit to construct.alter,improve,demolish,or repair any strucmx 1
prior to its issuance.also requires the applicant for such permit o file.signed sutemem POWER DEVICES ,C Q Nar he is licenseA pursuenno rhe provisions of the Contractor's License Lew(Cheper II
aid 9(commencingwiih Section71M0)of Division3ufthe Rusinexsend PrnfesslonsCWe) SWIMMING POOL ELECTRIC VALUATION
or that he is exon therefrom and the basis(a,the 011e edexem tion.An violation of
IkiJ=y p g p Any OUTLETS _ /'
�zG Section 703156y any applicant fora permit eubjectsthe applicrouoacivil penalty oftswas
� not team than five hundred dollen(5500)' NEW RESIDENTIAL ELECTR _S FT. -_ STORIES TYPE CONSTRUCTION
K t-o ❑ I,ssownernfNepropny,mmyemplayaswith wegesastheinol<compensntion,
y3200 will Jo the work,and the structure is not intended or offered for sale(Sec.7614.Business
and Professions Code:'Ilic Contractors License Law does not apply to an owner of
part who builds or improves thereon,and who does such work himxlfor through Ns
cmployeca.providcd Netxuch improvements uenotintendW proffered forsele.IL OCG GROUP RES.UNI'll
howcveq the builJingnr improvcmem is sold within oncyear ofcompinioo,Neowner- TOTAL:
huilder will have the burden of proving that he did not build or improve for purposeof
sale.).
❑ I,as ownerofthe prnpcny.amcxclusively. contracting with licemodcontractors to QTY. PLUMBING PERMIT FEE FLOODZONE APN
commas the pmicid(Sec.7W4,Business and Professions Cale:)The Contractor's
License Law does not applym anownerofpropcny,whobuildsorimpmves thereon,end PERMIT ISSUANCE
whoconrracrs for such projects with acomraetor(s)licensed pursuant tube Contractor's
License Ixw. ALTER-DRAIN&VENT.WATER EA) FEE SUMMARY
❑ I tet exempt under Sec. ,B&P C for Nis rex n BACK FLOW PROTECT.DEVICE OUTSIDE Fl;135
SANITARY Y N
Jwner Dale RECF,II'l'p
DRAINS-FLOOR,ROOF,ARBA.CONU.
ffWORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
1 hereby ansmr that 1 have a certificate ofconsent m adf-insure,or a certFlXTURES-PERTRAP certificate of RECEIPT'a
.,kers'Compeationlnsor.are or a ceirdind copy Nereof(Sec.3800.Lab C.)which PARK FEE Y N
covers of employee's under Nis permit. GAS-EA.SYSTEM-I INC.4 OUTLETS - RECEIPT.
Policy# BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(EA) PLANCHECK FEE
❑ Certified copy is hereby famished.
❑ Cenifed copy is fled with Ne city inspection division. GREASFgNDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' G P SOILS FEE
COMPENSATION INSURANCE
(This seetionnad not becomeleted ifthe permit is peris for one hundred dollars($HXE SEWERS ITARY-STORM EA.2or ENERGY FEE
or less.)
I certify that in performance perfounce of Nc work for which thin permitisiamed.Tshall WATERHEATER W/VE- /ELECIR
nm employ any person in any marten so as to become subject to the Workers' PAID
Z Compensation Laws of California. Dam WATER SYSTEMfO EATING Date Receipt a
Applicant
� Q NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should NEW RESIDENTIAL PI-MB. SQ.FT. TOTAL:
(q
become•ubjecun the Worker'.Compensation provisions of the Labor Code,you must
? forthwith comply with such provisions m this Permit shall be domed revoked. BUILDING FEE
G] CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm Nat Nem is o construction lending agency for the performance of
U O the week for which this poi Sect is issued( .3097,Civ.CJ L: I-- ELECTRIC ME
Leddrea Name
C' F Lenders Address QTY. MECHANICAL PERMIT FEE PLUMBING FEEV I certify that I have read this application arts aux Nat the above information is MECHANICAL ITE
>" W correct.l agree m comply with all city and county ordinances and suite laws relating to PERMIT ISSUANCE
E-' h bu0dingeo muction,and hereby authorize representatives of this city toemeruynn Ne CONSTRUCTION TAX
(, z ebovcmemioned property for inpe
sction purposes. ALTER OR ADD TO MECII.
1 We)agree to save,indemnify and keep harmless the City of Cupcnino against
liabilities,judgments,costs and ex n which may In any way accrue against said City AIR HANDLING UNIT(TO 10.000 CFM)
of�gm s mot. AIR HANDLING UNIT(OVER 10,000 CFM)
ww
gnatum J'ApEpliefunifiCistrutficar I Date EXHAUSTHOODOVMUC'p
PAID
HAZARDOUS MA'I'I?RIALS DISCLOSURE HEATING UNIT(TO IM."BTU) Date Receipt#
Will the applicant or future building occupant some or handle ha'rdedous material HEATING UNIT(OVER 100.0010 BTU) TOTAL:
u defined by the Cupertino Municipal Cale.Chapter 9.12,and the Health and Safety
Core,Section 25532(a)7 VENTILATION FAN(SINGLE RESID) r�
❑Yes ❑No
ISSUANCE DATE
Will the applicantorfuture huildingmsupant uxequipmentordeviecs which emit BOILER-COMP(3HP OR 100dD00 BTU)
vsrdous air contamimmis as defined by the Buy Area Air Quality Management BOILER-COMP(OVER 1W,WU B'IT)
surC1P O
❑yes ❑No NEW RESIDENTIAL MECII. SQ.FT. ` #
1 have sad the ha>ardom materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25574. 1 underswnd Nat �L ��
if the building does not.nand,Lave a fennel.that it is my respmsihility to nalfy the
cupant of the requirements which must be met prior to issuance of a Certificate of
Owner or amhori¢d agem Date TOTAL: ISSUEDOwner or Date TOTAL: ISSUED ByOFFIC
...:y. . . . .,.,,..r•. . ... ....., . ,��'r"'Mi1R+•P'.P.'^-"'?'+4.+"re r.+irrv.w vN.:wro�.�4y'F'f tirtijy{idf?Rrlt`r-N L`v •��.:^.i ..r•4v.ir,..,. - wr'.. ,,. ,e,
:# PERMIT P-15388
.CUPERTINO SANITARY DISTRICT -
Santa Clara County
20065 Stevens Creek Blvd., Bldg C, Fax (408)253-5173
Cupertino, California 95014 r .
Phone (408) 253-7071
CONNECTION PERMIT
R.O.S./P.M./Tract No. /3q o Lot No. /g
A.P.N.: Book 3 Z& Page_ Parcel O (V Date rV G f 26 I y�
Property Owner: G In , r ffN T N .0 vt p
Mailing Address:
(If different) ''rr
Telephone: 40 CL —25 7^ e7%e�
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
/b //O dm/40 nn Dr ,v& /0*74 -Wa
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.
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 of 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.
SPECAL 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: GG��-- $ 7�mU
Sewer Service charges to June 30, 105 ,$ 170 /mo.x_ mo.: $ �S7 SU
Inspection Fee for backflow protection device: $ 3�
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 compW::f
Acknowledgment:
Owner's Agent:
(print name)
Receipt of$ 4J.5' Cn acknowledged and permit granted.
MARK THOMAS &&CO., INC., DJistrict Manager-Engineer
byZ
Note:See Details on other side of this permit.
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
b, not to exceed five W feet.
c
J
T
w Removable Cleanout Plug
n
0
a Finish Grade
.Wye for Riser
-- Sewer Cleanout Box 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 g�J determined by building department
—CLEANOUT TO BE SAME SIZE AS LATERAL SEWER—
Notes: -
1. Distance from the property line not to exceed five(5')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 Jurisdictional Reatri.,mr.
Accepted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade Installed Below Grade Installed Above Grade
Shown Between Street RigM-o6Woy and Building Shown At Property Una Cleanout Shawn Adjacent To Building
Requires Regular Maintenance Reguii Minimum Maintenance Requires Minimum Maintenance
Valve To Be Removable Valve Should Be Removaale
VALVE ACCESS BOX FINISH FLOOR
with'Veined Cover
o Level of FINISw FLOOR
¢ KELLY VALVE
n'f nish Grade
VALVE ACCESS BOX KELLY VALVE s ?'
Finish Grade
Finish Grade
G
F
\' A F
BACKWATER
VALVE
FLOW Jd FLOW Dl FLOW n/
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.
g 4. If a Kelly Valve is installed at Property Line, it is to be readily removable for Lateral Sewer Maintenance.