15199 (2) SERIAL �.�1
SEWER CONNECTION PERMIT NO. P ' - 15199
CUPERTINO SANITARY DISTRICT R.O.S./P.M./Tract No.`.... r....... Lot No...9 ......
i
20065 Stevens Creek Blvd. A.P.N. Bk..c ............. Pg...�5.... Par!c�?/.-3....
Building C
Cupertino, California 95014
Phone (408) 253-7071 Date.... ...... ...............
The undersigned, being the owner(or owner's agent)of the property located at ........� ...
consisting of the following TYPE OF BUILDING:
Residential: Single family......X.. 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 ............................................................................ Building Depart-
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.....40C ??t"... i2xe n...................... Telephone..... /� 6 (2.4. o......................
Mailing address ifly
fi11 Zc 1 sD ®r 4
differentfrom above:..l......................................................................................../.......................
By%: / Gctiv //. .........
❑ A standard backilow protective device shall be installed, to the satisfaction of the Budding Department, for the above
property. (Note—See Detail I)
FEES:
Connection Permit Fee $...4n( ...
Sewer Service charges to June 30, 19.vy.,$.....A?......./mo.X.9..Mo. ........
Inspection Fee for backflow protection device
TOTAL $
110ceipt of$...`. .tea.... acknowledged and permit granted. MARK THOMAS &CO. INC., District Manager-Engineer
By..4� Z....................................................
NOTE:See Details on other side of this permit
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prn'ect Identification - ' PERMIT NO.
Bpi1ding.Adde - 2 2 919
tv-t%o �N N t>2
/e � �o�ne�:p A
L�.'Ov�,arsKD CITY OF CUPERTINO-BUILDING DIVISION / O ^ �y 1
Lie. : APPLICATION /PERMIT L 1--L
1 V^ ^ BUILDING-ELECTRICALPLUMBINGMECH LAICAL CATF-GORY CONTROL N
Archlled/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 1:1 ❑ 1�� 1:1LICENSED CONTRACTOR'S DECLARATION L�'
I hereby i firm n7ODthat)of Di licensed 3oftheunder uMnmalonsoff h msr9 de,and(commenc. MPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Infuti2000)anDiWslon3o(the Businessand ProlesalomCode,and my
rD.I,e
' isins fo and e. PANEIS /Q
e Class Lie. � L+
Contractor �!/j✓�
ARCHITECTS DECLARATION XII-1o00AMPS II
o4X rstandmp ah}Ilje used public records. OVER 1000 AMPS I�4/`�� FLppp �-pp- � $/SQ.FT.
U Fj cenwd Professional �r�C SIGNSELECTRICAL 0 V 0 p
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
s., 7, (hereby affirm that Iam exempt fromthe Contractor's License law fm the =I e I
7.oZfollowing reman.(SMlon 70315,Buelness and Pro(csslom Code:Any city or TEMP METEBORPOLEINST.
cmuntywhich requires a permit to construct,alter,improve,demolish,orrepair '
GY anystmcture prior to its Lwand,also requirestheapplicant for such permit to (OWER DEVICES
am..C Rk a signed statement that he is licensed pursuant to the provisions of the
3
tWJOwb, Contracture License law(Chapter 9(commencing with Section 2000)of Divi- SVOMMING POOL ELECTRIC VALUATION
On sioo3ofthe Buslnessand PmfmWmCode)orthathebeumprtthemfmmand
G S the basis for the alleged exemption. Any olao!Section 20315 by any OUTLETSSWITCFRSFTXfURFS
applicant for a permit subjects the applicantt to civil a civil penalty of not mare than
a
OR five hundred dollars(5 M. NEW RESIDENTIAL ELECTR Ff.
SQ STORIES TYPECONSTRUCT10N
❑e compensation,will
of the property,or he employed with ended as there sole
d for
C com(Sec.7Kwisiness and
rk,Pr and theswde:Thecture Is Contractorntended or License
Law
5 p sale(Sec.2004,BY91nn9and Pm(eulOm Code:The Contractors License LaW
does not apply to an owner of property Who builds or Improves thereon,and OCC.GROUP RFS.UNITS
a who doessuchwork hlmseBorthrough hisownemployees,provided thatsuch
improvementsare no,
anot intended or offered for sale.If,however,the build Ing or TOTAL:
i provementbwldwithinoneyearofcompletion,theowner-budderwillhave
tllLIlurden of proving that he did nm build or improve for purpose ofsalo). QTY. PLUMBING PERMIT FEE FLOODTONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntrac tommtmdthepmject(Sm.7044,BusinessaMProfessiom Code: '
The Contractor's License law does net apply to an owner o!property who ALTER-DRAIN&VENT-WATER(EA)Wilds or Improves thereon,and who contracts for such pwJeces with a
,,5W�actor(s)licensed Pursuant to the Conn
traors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under Sec. B&P C for this reason '1,110
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_R'TN ��
• Owner Dae RECFp
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL T" Y_ N_
❑I hereby affirm that I have a certificate of consent to Belf-Insure,ora RECEIPT N
ortlflcateof Workerd Compensation Insurance m a certified copy theremf(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,lab C.) p RECENT N
)'oIIryN O GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
l2gesnany
Peni0e copybhere mashed. CREASE/INDUSIRL WASTE INTFRCFPTOR PLANCHECKFEE
❑Certified copy b filed with the cityimpedion clMsion.
CERTIFICATE OF E%EMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.21)FT. Date Receipt#
(Thlsaecuon need not 1w completed lithe permit bfor one hundred dollars
($100)orl..) WATER I-�ATFR w/vENr/Et.ECTR ENERGYFEE Y_ N_
I c tifythat in the performance of the work for which this permit Is heuM,
I shall not employ any person m any manner so as to become subject to the WATER SYSTEM/TREATING
Wmkens'Compensation laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. 1 FT. Date Recei t1)
Z O NOTICE TO APPLICANT.It,after making this Certificate of Exemption,you
should become subject to the Wmlo,m'Compensation provisions of the Labor TOTAL:
T Code,you most forthwith complywhitsuch provblomorthis permit shall be BUIL TNG FEE
j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL
a Z Ihereby affirm that there bammtrudlon lendingagency forthe perform TO �r. ELECTRIC FEE
ince of the work for which this permit b blued(Sec.3097,Civ.C.)
U O Tender.Name PLUMBING FEE
LL F Lender§Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OU 1cetifythatI have read thbapplicadonand statcthatthcaboformation FEES PAID:
W lscorrect.I agree to comply with all city and county ordinances and state paws PERMITIS.SUANCE
} Nmlatingtobuilding comuuction,and herebyauthorbor representatives ofthls
city toenterupon the abovementioned property for Inspection Purposes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an it keep harmied the City of Cupertino Date Receipt#
L) against liabilities,judgments,orae and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against dCity in eon l the granting of this permit. CONSTRUCTION TAX
AIR IiANDW NG UNIT(OVER 10,000CFM)
Signature of Appll nt/Contractor ate EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppOcant m tutu ne building ompant store or hand le hazardous HEATING UNIT(TO 1 W,(D)BIU) Date Recef tilt
materul as defined by the Cupeti no Mu nidpal Cade,Chapter 9.12,and the -
lidlthand Safety Code Section 255320)? HEATING UNIT(OVER I(K000 BTU) TOTAL106
_—
❑ Yes , n No
Will the applicant orfuture building omepant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emdt hazardous air contaminants as defined by the Bay Area Air ^
Quality Management District? BOILER-COMP DHPOR 100,0(1)BTU r A 9 Q
Yes QNo
have re ad the har.ruous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I OCT 29 1gg,
understand that if the building does not ca ently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
respoesibility to notify the occupant of the requirements which must be met
prior to tscuance of a Certificate of 0c.p.ocy. CITY OF CUPEHTINU
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY