03050122 CITY OF CUPERTINO '-' i.n ' 4 "' 3"•"��"�` "'
BUILDING DIVISION PERMIT �CONTRACt,WIINFOORMAT ON .
BUILDING ADDRESS: PERMIT NO,
ABLE SEPTIC 03050122
PERMIT ISSUE DATE
520 REED ST. 05/27/2003
1 IT T11 I
SANITARY NO. CONTROL NO.
(408) 377-9990
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
¢
�Op LICENSED CONTRACTOR'S DECLARATION Ib Description
I Wreby.farm that 1.m licensed under providoos Oof Chapter 9(commencing ��W E�
i INS Oon7 )of Division Jof Ne Boo d Nor...Code,.ed my he,..is awl Era
'+<� nfull fo r. �A7�L�a�
p0Z Licem,Ci. , L'. ( CLEAN OUT FOR SANITARY SEWER
Data N it Gor
lD JUN 1 0 2003
undcrt).nd pl ns JUIf1EC1'SD in",
Odss
su0
Licensed Professional BUILDING
s� OWNER-BUILDER DECLARATION G
II 1 hereby orfirre that I am exempt from the Con rector's License Lew for the
-o O following mason.(Section 703 I.S.Business and Profession Code:My City m County
3$ which inquirex a permit to commuel alum,improv,demolish,or repair any structure
-Z1^^ prior W its ismance..tso requires to applicant for such permit in Bk a signed suemenl
< that he is licensedpursuanttotheprovialonofteConlracter'sLcense aw(Chapter9 Sq.Ft. Floor Area [� Valuation
Y�$ (Commencing will Section 7M)of Division 3 or the Business and Professions Codc)or $5200
Q ..
that he u exempt thcmfmm and the basis for the alleged exemption.Any Acted on or }s�N�srr�tv
Section 7031.5 by any applicant for a permit mhjecu the applicant to a civil penalty of 3 2 �`J-uU le�0 Occupancy Type
not mom Nen ave hundred dollars($500). 2 6 -uU
❑1,n owner of Oie property,m my employeu with wagas u their sole eompenudon.
will do the work,and Ne moon a isnot intended or.Bered for We(Sec.704x,Business
and Profession Code:The ConuactoY.License Law don not apply W an ower of 106 - SEWER ReggkTURSpections
property who buildsor improves thereon.and whodou such wmkhimsefor(hmush his 202 - UNDERFLOOR PLUMBING
own employees,provided(hat such improvements we not Intended monerod hassle.If,
however,the building.,improvement is sold Mthin.m yen ofwmpledon.the ower- 301 - ROUGH PLUMBING
builder will new the burden or proving ton he did not baud or improve for purpose of
507 7 - FINAL PLUMBING
sale.).
❑I,es owner of the property,am exclusively contracting with licensed conuectom to
Consumer the pm)ect(See,7Md,Business ad Profasaloas Code:)The Contractor's Li.
moss law does not apply to an owner of propeny who builds or impmws themon.and,
wheconacts for such projesn with a eontrector(s)Roomed putannt to the Conu ant's
License law.
lameaemp(under Sec .BQPCfmt1us..
Owner Date
WORKER'S COMPENSATION DECLARATION
I hemby frmn under penalty of perjury one of the following declarations:
I have
end will maintain a Cenificete ofConsenl W elf-inure for Workee,Compen-
W on,As pmvldod fat by Section 37M of the labor Code,for the Performance of the
work for which this permit is issued.
❑I hew and will maintain Workm's Compemadnn Insurance,As required by Section
3700 of the Labe Code.for the performance of the work for which this permit 6lssued. -
My kefs Compensslion lnmonce c.nicr and Policy n ber
r /LI'TI ✓/✓� Polity No:
C RTIPICATE OE E%EMPf10tJ MWORKERg'
COMPENSATION INStl ApKW
(This section need trot a completed lithe permit Is froom hundred dollars($101))
or lass.)
1 certify that in the perrormance of ow work for which this Permit is issued.I shall net
employ any person in any manner an as to broomm,mbjecuo the Workete'CoMMoSlu on
Laws of Califomia.Data
Applicant
NOTICE To APPLICANT:If.error making this Certificate of Exemption,you should
become sohject to site Worker's Compensation provisions of the labor Code,you must
Oforthwith Comply with such provisions m Nie pertnil tall an deemed revoked.
zr~ CONSTRUCTION LENDING AGENCY
FNi
. 1 arehy enlrm door Nem lea mrulrucu te.lending agenry for to performane,of
y'> Oie work for which this Permit Is issued(sur.309'1,Civ.C.)
aQ Undoes Name
=z Lcndee.Address
U0 I cenify that I have mad Oils application and state the,the show information is
LU F correct.I agree W comply with all city and county ordinances and sate laws Tabula&to
OV building construction,and hereby mhorim representatives of this city W enter upon ft
W above-mentioned property for inspection pulp..&.
4 (We)agree W an.indemnify and keep harmless the City of Cupertino again)
ILbilities,judgments,costs and expenses which may in any my atom tgaln(said City _
U Zin consequence of the stenting of this Permit
APPLI ANT UNDERSTANDS AND WILL COMPLY H ALL NON- NT Issued by: Date
SOU RE TIONS, S WITH
eC Re-roofs
S awrcuf AppliuMCommelor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building mcupen(nom or handle hazardous material
As de0md by de Cupcnlno Municipal Calc.Chapter 9.12,and ote Hearth and Safety
Code,Secti..25532UI7 All roofs shall be inspected prior to any roofing material being installed.
❑Y. ❑No
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.it narardoua air conuminanu as defined by the Bay Aro Air Quality Management all new materials for inspection.
District?
❑Yas ❑No
I hew mW the harardtms
.nie IOik SafctyCodc, mateJe.Iaifu.
SccumA2=.29533i=95
crnmtd Nnif the buildin&
d me unently hew•tenant Nu h h my Taspamibitily An lfy the occupant of Ne
aima •wnleH nm.nxmetpd.,W n.mm.r.cnreae .serer Signature of Applicant Date
Own,,m mdmlxsd/gem Dote 3 All roof coverings to be Class"B"or better
Rt
" PERMIT P-1 6 6 31
CUPERTINO SANITARY DISTRICT
Santa Clara County
20065 Stevens Creek Boulevard, Building C
Cupertino, California 95014 D f1 n�7
Telephone 408-253-7071 U
CONNECTION PERMIT IN 2003
Date ! n( (I ? APN: Boo ^}
�r ROS/PM/Tract/ o. Lot No.
:
Property Owner ` �f` �7 ';� F �, 1y1 �,'
f '
Mailing Address:
PAN
(I/We),being the owner(s)(owner's agent),hereby make application for connection of the at I ri 7
consisting of the following Type of Buildings:
Residential: Single Family Dwelling; Muld Family Dwelling_; No. Units
Commercial ; Industrial_; Other No. Units
• Do hereby request a permit to connect the sewer system of the Cupertino Sanitary District.
IN CONSIDERATION OF THE GRANTING 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 serviceable cleanout to grade
and accessible located within five feet(5')of the point of connection with the Lateral Sewer(that portion of the sewer in the
street right-of-way of District easement. c �, e , s+
3.To acquire a Plumbing Permit from the f 114' of �( ! ' !�_ :��! �V� ;Building Department and obtain the required
Building Department inspections and approval prior to use.
4.To expose and inspect for serviceability the Lateral Sewer 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 connect to sewer within one(1)calendar year from the date of issuance of this permit.
7.To call UNDERGROUND SERVICE ALERT(USA) 1-800-227-2600,at least 48 hours prior to starting construction.
8.SPECIAL PERMIT CONDITIONS: �Arkf(i�� I '1 .4"7i ( i)
/
tlx
® A BACKFLOW PROTECTIVE DEVICE shall be installed to protect 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: ,ti
Serer Service Charges to June 30, A 6
No..Units E x$ 16 t;i/month x /y no. months (31010)
r Backflow Protection Device Inspection Fee 1 ; :,.,'' (31020)
Connection Permit Fee: (31010)
1
Additional Connection Fees ( )
Total:
Considerations and Considerations of this Sanitary Sewer Connection Permit with attached Exhibits,are hereby agreed to
and acknowledged by the undersigned Owner(or Owner's Agent). Failure to comply may result in.termination of permit.
Acknowledgement: f 7af=+\
Owner's Agent:
(If Signing for Owner Please Print Your Name)
Receipt of Cl ! 1 ' i ,.--"acknowledged and permit granted.
MARK THOMAS & CO.,INC.,district Manager-Engineer
A
By
Revised 1/00 NOTE: See Details on other side of this permit
G`f-rw uhw
( f 1
1
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
not to exceed five(5') feet.
J
v Removable Cleanout Plug
dx
0
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
I alerol Sewer 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 dar'm diaignol Remimion.
Accepted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE 3
Inetolled Below Grade Installed Below Grade hnlalled Above Grade
Shown Between Street R,ghl-af-Way and Building Shown At Property Lina Cleanout Shown Adjacent To Building
Regmru Regular Me'mtenante Iw Requires Mlamum Maintenance Raoul-.Minimum Maintenance
Volvo To Be Removable Valve Should Be Removable
> VALVE ACCESS BOX FINISH FLOOR
f
Lu
KELLY VALVE
oc
VALVE ACCESS BO% EFinieh Grade Flnieh Gmde F
v'
BACKWATER n
vnlvE
FLOW Al' FLOW Al 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.
1 CITY OF CUPERTINO0 3 oS o Z Z
REPIPE/SEDERS/MAIN SERVICE
•CUPERTINO PERMIT APPLICATION FORM
APN # �(� ^OO Date:
S•- aa - n3
Building Address:
Owner's Name Phone #:
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Job Description:
Residential Commercia ❑
l
Cost of Project: _.p
•
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
•