25666 AFFLICAN i TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
U ILls1 C-hI. 6TR1 AL PERMITNO.
CITY OFCUPERTINO APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING DIVISION BUILDING PROLIFIC,IDEN'TIF'1CA'THIN 25666.
DING ADDRESS: SANITARYNO. API'LICA'110NSUBMITTALDATE
N3/`� a�� V l q� U V UN�� LOT is b
RS 4eniHONE: ACTOR' NA E' LIC NO:
NIC CONTROL#
RCH IC ANI GINEER: LIC NO: DRF R L' M _`^v
ONEFACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PGRMIT INFO
BLDG ELECT PLUMB MECH
-X67-5PERMIT ISSUANCE El D IJr_�yVJ/
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL
IOU DFSCRIPI'ION
OKZ Ibreebyaffirtmhat Dom licensedmob,„nisiat.d Chapr,9(commencing with
,x10W0 Section]000)of Division 3 of the Business and Professions Cade.and my license is in PANELS
F�UEfull force and effect.
FZW Licersu Class Lic.0 UPT02MAMPS
m=y Date Create r 201-1000 AMPS SQ.FT.FLOOR AREA, S/SQ.FG
Z�DZ ARCHITECTS DECLARATION OVER 1000 AMPS
O Z_E 1 understand my plans shall be used as public records.
LLW 1 SIGNS ELECTRICAL
Q�d Lidsmed Professional
Lii J OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC. I
KOyV I I hereby ahem shut 1 sm exempt from the Connectors License law for the
W 3 W rF¢ following rens....(Section 7031.5,Business send Professions Code:Any city m county TEMP.METER OR POLE INS . ^ A
5 to 0 ] which requires a permit to construct,alter,improve,demolish.or repair any shorten I n ! , e
2�J 7 miB issuance,uNorc uircstheu lican,for such po fle ass dxmtemen, POWER D17VICM u V
YYY prior 4 pp Pemti gnc
g!K<o that he is licensed pursuant to the Provisions of the Conummes License law(Chapter SWIMMING POOL EL1eCfRl ( �� `
D•0.o�G 9(commencing with Section 7”)of Division 3 of the Busi.ws and Professions Code) h'J A I VAfAAT10N
Wim or that he isenempuhercfrotn and the bnsisfw the alleged exemption.Anyviolation of OUTLCI'S-SWITCH -FI%TURES
Q Smion]03L3 by any applicemfora permit subjtttvhe applicvm to.civil penalty of
mom than five hundred dollars($5W).
O NEW RESIDENTIAL F. LTR _ STORI TYPE CONSTRUCTION
❑ Lnsoarsernf,heprnpeny,nrmyemployeeswith wagesmtheirsolecompenmtion,
LL will do thework,and the suucmre is not intendmoreffered hostile(Sec.]o44,Business
and Professions Cade:The Contractors License Law does not apply m an awns of
properly who hard,,,,improves thereon,and who dcessucb work himself",through his OCC.GROUP RES.UNITS
own employees,prov ided that such improvements arc not intended ur of&red for sale.If,
hnwevec the huddingor improvement N sold within one yeurofeempletion,themener- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose of
1e')' QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
❑ Lus owncrofthepropenY.umexdusively c.mrmtine with licenuA conwctonm
common the looter(Ste.7044.Business and Professions Coder The C.tmetor'a
License Law does.",applytoanownerofpmpcny whobuildsor improvesthercon,and PERMIT ISSUANCE
wImemnms fimsuch projects sithitembeconds)licensed fitmemnuothe Conwaor'a
License Law. pLTIiR-DRAIN&VENT-WATER(EA) FEE SUMMARY
❑ I me exempt under Sm. ,B&P C for this rcmon OUTSIDE FEES
BACK FLOW PROTECT.DEVICE,
SANITARY Y N
wner Dam pRA1N5-FLOORROOFAREA. RECEIPT#
, , . .
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N_
❑ (hereby vffrm,hatlhvveecrnificwc of consennoself-imurt,oraanifeme of RECEIPT#
ITXTURES-PER TRAP
Warkern'Compensmion Insurance oracmifed copy thereof(Ste.1gIXl,Lab CJ which PARK IEE Y N
covers sell emptoyee's under,this permit. GAS-EA.SYSTEM-I INC.40U'ILFTS RECEIPT#
policy p BUILDING DIVISION FE-ES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Criifedcopyisherebyfumished.
❑ Certified copy is Pled with the city inspection division. GRRASFJINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
comp ENSAT ON INSURANCE
(This section need..,be completed ifthe permit is Jerome hundnod dollars(8100) EWER ANITARY-STORM ENERGY FEE
or less.)
I comfy that in the performance of the work for which this permit is issued,I shall WATER HEATER W/VENT/L'LECTR
not employ any person in any manner so as to become subject to the Workers PAID
Z Compensation Lawsof Cellfomia. Dam WATERSYSTEMnRFATING Date Receipt#
Applicant
C NOTICE TO APPLICANT:If,after ranking this Certificate of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FT. TOTAL:
r .., became subject to the Worker's Compvnsauon provisions of the Lehr Cade,you must
forthwith comply with such Provisions or this permit shall bo deemW revoked. BUILDING TEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
,Zl hereby uffnd that is u construction lending agency for the performance of
O,
U ELECTRIC FEE
the work far which this permit is issued(Ste.709],Co.C)
lander,Name
u•' t—' Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING IEE
V I certify that I have read,his application addition that the above information is MECHANICAL FEE
�" OW.. correct.l agree to comply with all city and county ordinances and&rate laws cla,ing to PERMIT ISSUANCE
buitdingcommction,and hear,"uthonce reprsentmivesofthis city to enteropenthe CONSTRUCTION TAX
V Z above-mentioned p y for inspection porpoises. ALTER OR ADD TO MECH.
( (a)ag e,indemai d keep harmless the a Y of Cu ra JJJaJJJgai -t
liubilitics,j. r "costs cede swhichmayi%anyway center�dC'y AIR HANDLING UNIT(TO IU,OW CFM)
in conseyu c e the th pumit.
AIR HANDLING UNIT(OVER ID,IKgI CFM( i
Sign roof APplican C to Z Dme EXHAUST DOING WNUC) PAID
HAZARDOUS MATERIALS DISCLOSURE HEATING UNIT(TO 100,000 BTU) Dme Rttcipt#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) AL:
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? VENTILATION FAN(SINGLE RES1D)
11 Yes 13 No
ISSUANCE DATE
Will theapplicmmrfumrebuildingwupmtuseequipmentordevices whiehemit BOILER-COMP(3HP OR 100,000 BTU)
Norkm air emamerinunts as defned by,he Buy Arm Air Quality Management BOILER-COMP(OVER 1110,000 BTU) {p�
imuct? P pp�I� A O D
❑Yes ❑No NEW RESIDENTIAL MECH. SQ.Ff.
I epp
I have mod,he hexwdous materials requirements under Chapter 6.95 of the "'T 6L G
19
California Heudh&Safety Cade,Sections 25505,25537 and 25534. I understand that {20Y
Brie building dare no,currently have a mnsnt,that it is my rcspomibiliry to notify the
wcupam of the reyuirements which must h met poor m issuance of a Certificate of r I I Y f L
Occupancy.
"wee,m i m a rind agent Date TOTAL: ISSUED BY:
OFFICE
a
.,PERMIT P-15314 r
r CUPERTINO SANITARY DISTRICT
� .
Santa Clara County
t 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. Lot No.
A.P.N.: Book 357 PageO Parcel // Date C/'c
Property Owner: 5e,h 1 Q 2 , R u e p t.'-,' A
Mailing Address: 2-2Z8( BF—ItE-VU); fWE-
(If different) C J P 6+4 r rJy
Telephone:
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of tqqa property at:
2228 ! 13 _ / i eVL)Lr-frr�o
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family X ; 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). L
3. To acquire a Plumbing Permit from the �r of 6y 10 Pte✓ I' V Building Department and obtain
inspection and approval by said Building Department prior to covering of the work or use of the sewer. It
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
r�
t
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:
u "
Sewer Service charges to June 30, 192,$ 16 S /MO. x_)mo.: $ 141
sw
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:
.14
L/ J
Owner's Agent:
(print name)
Receipt of$2 z# 5p acknowledged and permit granted.
MARK THOMAS&CO�, INC., District Manager-Engineer
Note:See Details on other side of this permit.
f
t ;
' t
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
ba
not to exceed five(5�) feet.
J
d
Removable Cleanout Plug
n
0
M Finish Grade
..k., .
Wye for Riser Sewer Cleanout Box with Lid to be accessible
and maintained by property owner.
Short length Riser Pipe
1/B Bend
Adaptor coupling
FL`�OW r
LaieralSewer
House Sewer
_—V
Lateral Sewer slope House Sewer slope
determined by Distriot 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.
1 3. The maintenance of the Lateral Sewer Cleanout is the responsibility of the Property Owner.
f 4. House sewer minimum slope determined by local Building Department plumbing code requirements of the
• ` agency having jurisdiction thereover.
I .
TYPICAL BACKFLOW PROTECTIVE
DEVICE INSTALLATION
TYPICAL BACKWATER VALVE TYPICAL KELLY VALVE INSTALLATIONS
INSTALLATION Jurisdictional Restrictions
Acupted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE Above
3
Installed Below Grade Metallic Below Grade lose Adjacent
centre Grade
Shown At Property Line Cleanout Shown Adjbpnt To Building
Shown Between Street .ot,si iretWGY and Building if Minimum Maintenance
Require, Regular Molnlenance z Reauirae Minimum Maintenonu Volvo
J
Valve To Be Removable Va Ne Should Be Removable
> VALVE ACCESS BOX FINISH FLOOR
be
with/Vented Cove,
Ao Level of FINISH FLOOR KELLY VALVE
o e
' A ^_+� mien Grade
VALVE ACCESS BOX KELLY VALVE
F
Finish Grade
Finian Gratle m \
BACKWATER n
VALVE
� FLOW Al
FLOW A FLOW al
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.
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