29664 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. ^^ ^
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL L 9 b
BUILDING PROJECT IDENTIFICATION
UIADDRESS: vi �a/5� SANITARY NO. APPLICATION SUBMITTAL DATE
�
C va CA
0 NER'S NA PHONE: O"R'S 'A 13: LIC NO:
11Gk -� NIC CONI'ROLM
xehn
CHITECT/ENGINEER: LIC NN G ADDRESS: C- N ❑
CONTACT: �,ddc; 0Ya9�1'n/Da✓iHONF:: �.3ol ❑ Consultant Fees Paid by Applicant(Initial) RUGG BUIIELECT PERMIT INFO MECH
3 ❑ ❑ � ❑
1.10ENSen CONTRACTOR
under9nEConunnop QTY. ELECTRIC PERMIT NEE
I ion 7 .farm that I an licensed Bd under provisions ofcouple,Code. 9(m licendns JOB DESCRIPTION
�OOZ wish Nation]000)0(Uivision3uf the Business and Professions Code.and my license is PERMITISSUANCE RESIDENTIAL:
F in full fora and effect. DSFDWL D KITCHEN REMODEL
aUF License ClaesI'mN
G DateCentralia
Q U APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTSSDECLARATIONL
ARCHITECTS GMUI-TI-UNIT C1 STRUCTURAL
ZOr�sZ lundcmmnd my Plans shall he ural n<puhlic records PANELS MODIFICATION
pz,..Q UP G)20(1 AMPS ❑INTERIOR El CHIMNEY REPAIR
4F'ly Licensed Professional ' 201-I00OAMPS IMPROVEMENT
C Y J OWNER.BUILDER DECLARATION OVER 1000 AMNS [I BATH REMODEIIREPAIR DDE' LITTON
tX 1 hereby affirm that I am exempt from the Contractors License Law for the
P.U followin reason.(Nation]031 s,13mo uss and Pro!ssions Cada An t I El OTHER
g y ci y nr coon y SIGNS(ELECTRICAL
31+-pFj which requires a permit to construct,alter,improve,demolish,or repair any structure
0 pdo,as its isaaance,akm requites the applicant farsuch pennitm file.signed sta¢mcrn SPECIAL CIRCUIT/MING.
} that he is licensed puraunsm the Isardoonsafthe Com racmrs License Law(Chapter 9
of (commencing with Second 7(401)of Division 3oldw 13.6msaand Ponfeeinns Code)ar TEh11'.MET[R OR POLE INST COMMERCIAL:
a a v 5 that he is exempt therefrom and the basis for the alleged exemption,Any violation of D NEW BLDGIADDITION D D17MOLITION
^N
Section 7031.5 by any applicant for a perminsabjects the applicant o a civil Penalty of POWER DEVICES DTENANT ❑FOOD SERVICE
not mom than five hundudi dollars(5500).
y'-Y OTHER IMPROVEMENT
=r6 wi Lo are work.
.lnd pmpeay,omycmployros with wages astheir wee a0m,Business SWIMMING POOL ELECTRIC
FFG will dothcwons Code:
structureContractors,is not License
nsorow does
apply toan
wnerof []OTHER
gj—m and my who CWe:The Contraem, Licenx law Does not apply man owner of OUTLETS-SWITCHILS-FI%TURES
a 3_ pmpcny who builds or improves thereon,and who Jces such work himsdPor Ihmugh
his own ensployeex,provided that such impmvemems ole not intended m olTared far NEW RESIDENTIAL ELECTR SQ FT.
sale.If.however.the building or improvement is sold within one year ofeempletion.the Q.FT.FLOOR AREA EISV.FII
' owner-builder will have the burden of proving that he did net build or improve for pur-
pnsc of eric.).
❑Les owner,of the property,am exclusively coneraaing with licensed contracture to TOTAL:
drandruct the project(Sec.7044.Business and Professions Code)The Contractors Li-
came law Jces not apply to an owner of property who builds or improves daemon.and QTY. PLUMBING PERMIT FEE
who commcte fur such pr jests with v wmmcasr(e)lica,ad pan,aanuo the Contactors
License Law. PERMIT ISSUANCE
I am esempt under Sec. .R h P C for this.0.
Owner Data ALTER-DRAIN&VENT-WATER IIII VALUATION
WORKER'S COMPENSS17ON DECLARATION BACK FLOW PROTECT.DEVICE
I hemby affirm under pcn.lty of perjury one of the following dcdarationc
❑I have and will maintain a Certificate of Consent to stlGinsurc for Workers Comism- DRAINS-FLOOR,ROOF AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided ha by Section 3700 of the Labor Cale,for the performance of the
work for which this permil is isncd. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700nfthe Labor Cade,for the performanceof the walk for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Cmnpensvtion Imumvee carrier and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(F�)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASErINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION ICES
(Thi e semian need nm be mmplGcd if the purmhle latmnc M1undred dollars(EI(k) CR13A58 q'RAI'
or IessJ PLANCI{CCK FEE
I certify that in the perform.nceofthe work for which this permiti cm, "shall SEWER SANITARY-STORM 00.200 F1'.
net employ any pe,,an in any manna,so us to became subject In the Workm'Cumpea- ENERGY FEE
zZ cation Laws of Califamia Dam TER HEATER W/VENT/ELECI'R
Q Applicant GRADING IT
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
F ; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS NEE
forthwith comply w lin such provisions or this permit shall be decnued invoked, WA'T'ER SERVICE
0
a'
CONSTRUCTION LENDING AD BEY NEW RESIDENTIAL PCMB, SQ.FT. PAID
IherehY uffinU0n tom there isvcnnstmninn lending asencY lar the performance of Data Rccciptro
(•-' the work for which lhis permit is lesual(Sec.3097,Civ.C)
IL Lenders Nome _ TOTAL
U Lender's Address AL.
IllBUILDING FEE
1 certilY That 1 have read this application and stat that the above Inasonmion ix
Tia carrect.l astee memnply with all city and county ordinances and tram lows mining to QTY. MECHANICAL PERMIT FEE
V z building construction,-ithereby aiducrinamptt,culdivexofthis city w ariterupon the SEISMIC FEE
alsuve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree it)save,indenmify and keep harmless the Cay of Califon again ELECTRIC FEE
Iiabilities,judgmems,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this Permit. PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10,011(1 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER I0,XXICFM) CONSI'RUCTIONTAX
'ignaturt of ApplicanVCantmmm Date EXHAUST HOOD DGDUCT) HOUSING MITIGATION FEE
HA7ARDOUS MATERIALS DISCLOSURE
Will theapldhernt isfuturaloildingnacupanunmofhandle hvromm,mnerial HEATING UNIT TO IMJW RTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,coal the Health and Safety
Cale,Section 25532(a)] HEATING UNIT(OVER HpA00 BTU)
[:1 Yes Oso PAID
VENTLLAI'ION PAN(SINGLE RI3SIU) Date Receiptk
Will the appit..,or future building de,.....ase equipment or devices which
tit haranlnus air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(SHP OR 100,000 BTU) AL
DlsteicYl BO]LER-COMP(OVER IM,(XX)BI-U)
❑Yes GNn
I have re ad the nuanim,imam.",requirements under Chapter 6.95ofthe Cali- AIR CONDITIONER ISSUANCE DATE
funis Health&Safety Code,Sections 25505,25533 and 25500.I understand that if the NEW RESIDENTIAL,MECH. SQ,hl'.
Wilding does net currently have a remain.that it is my responsibility hs madfasho,nvcupant
of m 2h matt and p' u anfa Can,
Ownerorare�daed.liam Duro TOTAL: ISSUED BY:
OFFICE
My w�,•... .-�...^.y.�,h-rri•.,..,.y,..4t".... v.T^'f Rn,.rt:.• v^[f5 t(4""'xtNrS �' .:4'y�,rr,.,M'ri.-�M?:-v4"tiy'7'. .f\:.^..vM'¢'.:^n!"'r^� , ..a
PERMIT P-15575
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.fTract No. / �'� Lot No. _ !� / I q
A.P.N.: Book 3Z& PageH J� Parcel O 10 Date 23,
C,
Property Owner: Ja K k. -�f �&V 0A >f�- 1 a /
Mailing Address: 1e1160 A/!a n n PP-
(if
r(if different) j � e'� 9S-01-1
Telephone:
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the property at:
/dh/DO �//lar�r� Dri✓� �u�o>✓r �h U
consisting of the following TYPE OF BUILDING(S): ,
Residential: Single Family y ; 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 Lt/ hU 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.
&hat this permit does not constitute a request for the issuance of allecroachment permit for sewer construction in the
street/public right-of-way of the agency having jurisdiction thereover.
To call Underground Service Alert(USA) 1-800-227-2600, at least 48 h- prior to starting grading,pr digging operations.
IECIAL PERMIT CONDITIONS(Exhibits):
nA 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:
n O
Connection Permit Fee: $
ew, OAU
Sewer Service charges to June 30, 11916 's Pg' /mo.x S mo.: $
Inspection Fee for backflow protection device: $
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:
(print name)
Receipt of$ 11�6 o acknowledged and permit granted.
MARK THOMAS &CO.,INC., District Manager-Engineer
Note:See Details on other side of this permit.
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
not to exceed five IS) feet.
J
v 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 l/B Bend
—FLOW m
Lateral Sewer I House Sewer
Lateral Sewer slope House Sewer slope
determined by District 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 Realricliona
Accepted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade Installed Below Grade Installed Above Grade
Shown Between Sliest Right-of-Way and Building Shown At Properly Line Cleanout Shown Adiaca hit To Building
Requires Regular Maintenance i Requires Minimum Maintenance Requires Minimum Maintenance
Valve To Be Removable Valve should Be Removable
VALVE ACCESS BOX FINISH FLOOR
7
A, wilvventait Cover
o Level of FINISH FLOOR
Ic
KELLY VALVE
tKELLY
VALVE ACCESS BO% EFinish GradeFinian Grade
BACKWATER in
VALVE
FLOW n/ FLOW A FLOW A/
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. H a Kelly Valve is installed at Property Line, it is to be readily removable for Lateral Sewer Maintenance.