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22527 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY building Project ldcmi(icaion PERMIT NO. Building Address: (/ 22527 , acre: / : A A A IL Ale- 40oe 2 S� %0 6 Z 2 CITY OF CUPERTINOIBUILDING DIVISION _ ^ _ / C 5 . r:� S (,� g Li .: APPLICATION /PERMIT / N BIRLDING-ELECTRICALnIJMBING-MECHAMCAL CATEGORY CONTROL N Lk.No: ArchltM/Engineer. ,// — QTY ELECTRIC PERMIT FEE BUILDING PERMIT I��l PLUMINNFO Address O a OI O .LY/� PERhIlTISSUANCE ❑ 1:1 �rY ❑ LICENSED CONTRACTOR'S DECLARATION CJI Iherebyafftrm that l am homsed under provisions of Chapter 9(cornmento APPLIANCESREMDENT'IAL JOB DI5CHR'IION ingwith Section 9000)of DiWslon3 ofthe BuainessandProfesalonsCode,and my Lkxan ialnfunforce and died PANELS Llcenx Cion—tee Comrade, e, /0 v \V Y1�1�11� Data Contractor UP TO 2DO AM 2011000 AMPS ABCHITE ECLARATION s7 I understand my phrs snap heusedas pubbc records OVER]000 AMPS SISQ.FT. Ob pQ!u� klj Licensed FT. EA Professional SIGNSELECTRICAL �' ' N < OWNER-BUILDER DECLARATION 7 F'a Y SPECIALCIRCUIT/MISC T R sal-� Ihercb affirm that exam from Contractor's License Law the U qQ following reason.(Season 7Q71.5,Business and Professions Code:Any city or T / 0 cauntywhichrequirnapert ttowmma,alter,bnpmvgdemolbh,ormpair TEMP.METIER OR POLE INST. ,� /j Ga6g) anyatructureprlormitsis,sante,aborequlreatheepplkant(orsuchpermluo POWFR DEVICES DATE - `� c.S file a signed statemente Is licensed that hlicensed pursuant to the provlslom of the O r:� Contractors License Low(Chapter 9(commencing with Stolon 9000)of DIW- slon3ofthe Business and ProfessionsCode)orthat he isexempttherefromSWATh9NG POOL ELECTRICand VALUATION the basis for the alleged exemption. Any violation of Seaton 7MI5 by any OVILE1SSW1'ICHESHJ(TURES <Oi appna rn ontfor a permit subjects the applicant toot civil Penalty area t F, five hundred dollars($500). NEW RM- DENTIALELE-CTR FT. ?�n ❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUC'T'ION mmpersatlon,will dothe work,and thestmcture Is not Intended or offered for sale(Sec.9044,Business and Prefesslons Code:The Contractors License Law does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS 0.0. who don suchwork himselforthwgh his own employers,provided that such improvement arc not intended or.ffered!or sale.If,however,thebullding or TOTAL: improvement tsold withinonerarofcomplaiogthe owner-W dderwill have thv*rdenofpceving that he did not bund orsmperve for purpose.tub.). QTY. PLUMBING PERMIT FEE Ll L as owner of the property,am exclusively contracting with llcensed FLOOD ZONE APN PERMIT ISSUANCE ntraa.m to construct the projea(Sm.7044,Business and Professions Code: m �ZDo The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VENTWATER(EA) Wilds or improves thereon, and who contracts for such p4ojeas - - with a - FEE SUMMARY �gRtfactor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE Lf I am exempt under Sec. B&P C for this mason OUTSI[)I.FEES Owner Dale DRAINS A,FLOOR ROOF,ARECOND. SANITARY Y_ N_ WORKMAN COMPENSATION DECLARATION REBBC=N EN !• ❑I hereby affirm that I have a certificate of consent to self-Insure,ora FIXTURES PFA TRAP SCHOOL TAX Y_ N_RECEIPT N certificate ofWorker,'C.mpersati.n Insurance or a certified copy thereof($ee. GAS FA.SYSTEM-1 INC.4 OUILLTS PARKFEE Y N 3800.Lab CJ pppppp Policyp1 � RECEIPT GASEA.SYSTE?vI-OVER4(EAI Com anv. SSS/-b K/ BUILDING DIVISION FEES � rtNed copy t bedwith the GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE �rtl(ied copy Is(fled with the sty Wpectlon division. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-STORM EA. Date Remi t# ffhisxet b . .aion need n e completed If the permit Is forone hundred dollars .'�� (SI(D)°`less') WATER HEATER W/VENT'/dFLTR ENERGYFEE Y N_ I cema rtify that In the performance of Me work for which this permit Is Issued, I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Workers'Compensation laws of California. Date - PAID O Z Applicant NEW RESIDENTIAL PL.MB. SQ.FT. Date Revel t# Z O NOTICE TO APPLICANT.If,atter making this Certificate of Exemption,you should become aubpTd to the Workers C.mpemation prevision of the Labor TOTAL: Code,you must f.rthwith comply with such provislom or the,permit shall be W > deemed revoked. BUILDING FEE CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE I hereby affirmthat there is a construction lending agency for the perform ELECTRIC FEE 7 Z anof the work for which this permit Isissued(Sec.3097,Civ.G - TOTAL: 77_._44b_ U O Lander,Name PLUMBING FEE /'j,00 LL H Larder's Address QTY. MECHANICAL PERMIT FEE O w Icertifythat l haveread thisappnotlonandstatethattheabovelnformatlon MECHANICAL FEE O. Iscorrea.iagreetocomplywlthalldtyandmuntyordbanoesandstatelaws PERMIT ISSUANCE FEES PAID: relating to building construction,and hereby authorize representatives of this N city to enter upon the above-mentioned property for Inspection purposes. ALTFAORADDTOMEGH. Z (We)agree to save,Indemnify an d keep harecleu the City of Cu pertbo Date Receipt# V against liabilities,pdgmcnb,mets and expenses which may In any wayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: agar said Cityi consequence.fthegrantingofthIspermit. AIRHANDLINGUNTT(OVER10,000CE) CONSTRUCTION TAX �� C7'7�� Lure of Appnam/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applies nt or future building occupant store or handle hazardous HEATINGUMT(TO100,000BTU) Date ReceI t# material a,defined by the Cupertino Municipal Code,Chapter 9.12,and the - Ilealthand Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: /10'0 ❑ Yes M No Will the applicant or building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSJIANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management Dttrict2 BOfLER-COMP DHP OR 100,000 BTU) 4Yn ❑❑No havcreadthehuardousmaterials requirementsunder Chapter 6.95o( BO ER-COMP(OVER 100,0008 U the California lhealth&Safety Code,Sea ions 25505,25533 and 25534. I ( }nta� understand that lithe building don net currently have.tenant,that It 1,my NEWRFSIDENTIALMECH. SQ.IT f�a_i`CY responsibility to notify the occupant cfthe requirements which must be met u prim to issuance sat a Certificate of Occupancy. (� Owner or authmirxd agent Date TOTAL: ISSUED BY: OFFICE COPY �� 2252'7 ✓ SERIAL SEWER CONNECTION PERMIT NO. P i 1 5 1 7 1 *CUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No..l.3.9 ... Lot No.. .16r'. 20065 Stevens Creek Blvd. A.P.N. Bk... .U....... Pg..15?...... Par Building C Cupertino, California 95014 ++ 1 Phone (408) 253-7071 Date...�1`. � �'S..{....l�................... 19��. �... The undersigned,being the owner(or owner's agent)of the property located at ........................................................ ....... /! /G.......f.�/moi.!?.✓?... T�r�....�`..F, <� consisting of the following TYPE OF BUILDING: Residential: Single family....X..... Multiple............ No. Units.....I...... 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 propert line or at the limits of any exis ing District easement. (Note—Detail J) 3) To acquire a permit from the ....CL .. «� ... l t 1 '" ... Buildin De Depart P `1....................t...... ............................... g P ment and obtain inspection and approval liy 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.�/, E ....h........................... Telephone... .-�... .......G'....z................ ... Mailing address if different from above.... {Je..��.........................................� ................... ........................... By�/� ..... J...................................... ❑ A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above property. (Note—See Detail I) FEES: c � Connection Permit Fee $...2 Sewer Service charges to June 30, 19e.-)..2.1 $... .../mo. X. mo. j/l, Inspection Fee for backflow protection device � o TOTAL $ jWceipt of$J.3.......... acknowledged and permit granted. MARK /THOMAS /&CO. INC., District Manager-Engineer By—..... 7C..�G�/tom` NOTE:See Details on other side of this permit CUPERT/NO SANITARY DISTRICT r NOTES: All solves to be accessible and moidtamed 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. J w Finish Flo r Level 3 c Kelly Valve Finish Floor Level E Finish Gradeeatiols see Kelly Valve—' �yyB F Volvo Access m._ with Vented Cuter ` qE Volvo Access Box B dYt Backwater Valve y Figure I Figure 2 Figure 3 Kelly Valve- Below Surface Backwater Valve—Normally Kelly Valve-Above Ground Installation-Shown al required installed or shallowest point Inetnllotill Shown installed Property Line Cleau l along House Sewer between close to building. Property Line and building. DETAIL STANDARD BACKFLOW PROTECTIVE DEVICE INSTALLATION I ±, Io,'e`cZ to be as ble. vable Cle onwt Plug h GradeWye for Riserwer Cleanout Bos with Lid to be accessible Short length maintained by property owner. Pipe Adopter couplingd FLOW m Lateral Sewer House Sewer FOT E: ��nimum elope determined by Building Department. Lateral Sewer Cleanout to be same size as Lateral Sewer. DETAIL STANDARD CLEANOUT FOR LATERAL SEWER J