26487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTPERMIT N°'
PLUMBINGMECHANICAL
BUILDING DIVISION HIIILUINOPRI.IR.QI'IDP:NTINIhAIION SO
,
BUILDING ADDRESS: 1gra SANITARY NO. APPLICATIONSUBM'DTIALDATE
'4 C�.i W\ UNIT LOT w�
OW � AME.: 1 �a CONT A �R'S NAM^ep4iN
�Cf7( N/C CONTROL
ARC111TCCT/IiNGINEFR: LIC NO: A A ` Q ❑
ONTACI': PHONE: 1K✓V o
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ El -a ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL JOB DESCRIPTION
PCZ Iherebyaffilm that l am licensed unlarprovisions of Chapmr9(cemmening with
1-400 Seow7000)nf W Dlviston 3ofthe Ban
usineasd Professions Code,and my license is in PANELS
e,
E full force end-flat.
Q ZZ5 Licenu Class Lim.It UP T0200AMPS
rat 6 y Dun, Contractor 201-1000 AMPS
ZDyZ ARCHITECTS DECLARATION SQ.FT.MOOR AREA $/SQ.FT.
O Z^O understmtl my plans shall be used m public records. OVER 1000 AMPS
r,
SIGNS ELECTRICAL
gLicenmd Professional
ns�U OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
0xU 1 hereby affirm that 1 am exempt from the Convector's License Law for the
m 3 a m following reason.(Section]031.5,Business and Professions Code:Any city or county TEMP.MBTER OR POLE INST.
(_ which requires a permit to<omtmcl,altar,improve,demolish,or repair any mouse
� prior to its issuance,also requires the applicant for such permitto file a signed statement POWER DEVICES
wthat he is licensed m
tl puuthe provisions of the Contractor's License Law(Chapter
9(
d (commencing SWIMMING POOL ELECTRIC t V�LhQp'pON
Wp� gwith Section]000)ofDivisionJof Ne Business and Professions Code) PI
rpy'^so or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FIXTURES
m
GSection 7031.5 by any applicant for a permit subjects the eppiicanuo a civil penalty of ! 0 I_
not more 1, than rofthehundred
ay.ormy(Np. NEWRESIDENTIALELECTR Q.FT. TO TYPE CONST RUCTION
22 ❑ hmownerand-progeny,orntyemdended whffirom aethe(See.comtemation. C f!
y will dotheand theses CmInnaotimm�emseafwdoes not
Business ATL
and Professions Cod-:The Centhemon. nd who Low aces not lumet w rt owner of L
propenyw,ces. ovidedp eneathefeon,anrnmass not t such
monde.
CUR RES.UNITS
con emplthe butProvidea thatsuch improv sold
wit arc not immntles moffered forsol n If,
builder ,wtheavet a burden of pmentishathedidnot year ofcoprove for
of TOTAL:
builder will have the burden of proving That he did not build or improve for purpose of
ale.).
❑ 1,ae owner abbe properly,amenelusively connwting with licensed conuacmntt QTY. PLUMBING PERMIT FET? FLOOU'LONE APN
construct the project(Sec.7014,Business and Professions Code:)The Contractors PERMIT ISSUANCE
License Law does not apply m an owner of property who builds m improves thereon,end
whoconrais forsuch pot with sconuactans)liceamd pursuant lathe Coneracmrs se Law. P,NFA
License
ALTER ( ) FEE SUMMARY
❑ l nn exempt under Scc. ,B ffi P C fur this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY YN
Owner Date DRAINS-FLOOR,ROOF, GONDRECEIPT It
WORKMAN COMPENSATION DECLARATION , , . SCHOOLTAX YN
❑ I hereby affirm that l have a cenifican ofconssnuo self-insure,ora c-nificaeof FIXTURES-PER TRAP RECEIPT
trk-n'Ctmpnetion Insurance ma certified copy lhemol'Sec.3800,Lab C.)which PARK FEE Y N
oven all s mptoyet's an&,this permit GAS-EA.SYSTEM-1 INCA OUTLETS RECEIPT 4
'olicy 4 BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(G) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ CeAfed copy is filed with Ne city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE,
COMPENSATION INSURANCE
(This section need not becompleted ifthe permit is for molundrdidollarst SI00d SEWER-SANITARY-STORM EA.200FT. ENERGY FEE
or less.)
I cenify that in the Performance of the work for which this permit is issued,l shall WATER HEATER W/VENTIELECTR
nm employ any person in any manner so as In become subject to the Workeri PAID
z Compensation Lawsof California. Dam WATER SYSTENUTREATING Dna Receipt If
Applicant
Q NOTICETO APPLICANT:Tme,makingmix Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
sV) become subject to the Worker's Compensation provlslonsof the Labor Code,you most
a , forthwith comply with such provision radar permit thallh domed revoked. ` BUILDING FEE
k0
z
CONSTRUCTION LFNDING AGENCY SEISMIC 17EE
v
I hereby affirm That there is a U construction performance lending agency for the perfor ¢e of O the work for which this petmil is issueded(See 7097,Civ.CJ ELECTRIC FEE
Lenders Name -
0 U Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEF. �.
I a1 cenify that I have read this application and state that the above information is MECHANICAL FEE
correct. l agree to comply with all city and county ordinances and mum taws mining to PERMIT ISSUANCE
Cn building concoction,and hereby amharim,rapmorntadves ofthis city menterupon the CONSTRUCTIONTAX
V 7 aMve-mentioned property(a,inspersion partners. ALTERORADDTOMECH.
G7 (We)a rx m save,indemnify and keep harmless the City of Cupertino against
liabil" ,) ghee .ve.Indemor, andnprntes which may" anyway cof Cupertino
'y AIR HANDLING UNIT(TO 10,000 CFM)
ms egranlin6 of lhi. it.
00, AIR HANDLING UNIT(OVER 10,000 CFM)
Sig are of Applicans/Cmdmcmr Dem EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MATERIALS DISCLOSURE
BEATING UNIT(TO 100,007 BTU) Data Receipt 4
Will the applicant or future building occupant them or handle hnnrdous material HEATING UNIT(OVER 100,"BTU) TOTAL:
os defined by the Cupertino Municipal Code.Chummf 9.12,and the Health and Safety
Cale.Section 23532(a)'1
❑Ycs CI No VENTILATION FAN(SINGLE RPSID)
ISSUANCE DATE
Will theapplicamorfumabuildingaccup tunequipmenmrdeviceswhichemit 0X
BOILER-COMP(3HP OR 100, 0 BTU)
azmdom air contaminants es defined by the Buy Arco Air Quality Management BOILER-COMP(OVER 100,00)BTU)
oriel) k^
❑yet ❑No NEWRESIDENTIAL MECH.-SQ.FT.
1 have read the hamNons materials requirements under Chapter 6.95 of the r-I�I11 . F� �JVaa��
Culifmmiu Health&Safety Code,Sections 25505,25533 and 25534.1 understand that V 1� I
if the building does not currently have a boaa4 that it is my responsibility to notify the
o ccu m of the requirements which must b,met prior m issuance of a Cmtif tale of C�1Y tar a;uI
Owner or amhodaed agent Data TOTAL: ISSUED BY:
OFFICE
�.,. *.PERMIT P—Z5355
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./Tract No. Lot No.
A.P.N.: Book 3 5 9 Page O Z Parcel 62 ! Date /✓r 2 9 % 7
t
Property Owner: J a S c% L 1 n
Mailing Address: /O D 4(o $ 1 o.ti,e � j l.)
(If different) �'v 1�PPA ki o I CA- 96-0 N
Telephone: 9 7 3
Sirs:
(I/We), being the owner(s) (owner's agent), hereby make application for connection of the proRarty at:
1004,0 - /pod(o '8ta.A.tc
consisting of the following TYPE OF BUILDING(S):
Residential: Single Family ; Multiple Familycam; 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 (11,
/r of LiI ig e4- 4 ri D 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$,-)r
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):
r
❑ 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: $
Sewer Service charges to June 30, 19_�41 , $ /to fo /mo. x Z mo.: $ 32 P
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.
i
Acknowledgment:
Owner's Agent:
�o (print name)
Receipt of$ �� $� acknowledged and permit granted.
MARK THOMAS&CO., INC., District anager-Engineer
by'
Note:See Details on other side of this permit.
,
TYPICAL CLEANOUT FOR LATERAL SEWER
Distance from Property Line
to be as close as practicable,
°i not to exceed five IS) feet.
c
J
m
Removable Cleanout Plug
m
a
Q. Finish Grade
Wye for Riser Sewer Cleanout Box with Lid to be accessible
and maintained by property owner.
Short length Riser Pipe
I/8 Bend
Adaptor coupling
FLOW m
Lateral Sewer House Sewer
Lateral Sewer slope House Sewer elope
determined by District EIJI 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.
dl. House sewer minimum slope determined by local Building Department plumbing code requirements of the
agency having jurisdiction thereover.
' - TYPICAL BACKFLOW PROTECTIVE
DEVICE INSTALLATION e
TYPICAL BACKWATER VALVE TYPICAL KELLY VALVE INSTALLATIONS
INSTALLATION Jurisdictoral Restrictions
Accepted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE 3
Installed Below Grade Installed estate Grade Installed Above Grade
Shote.Between Strut Rlaht-.I-Way and Buldinp eboten At Property Line.Claanoul Sbavn Adjacent To Buildlnp
Requires Minimum Maintenance Requires Minimum Maintenance
Require. Ruular Mainlenanca we
J
Valve To Be Removable Valve Should ee Removable
> VALVE ACCESS BOX FINISH FLOOR
tel Ovinal I Cover
C val o Fj 1; M'FLOOR KELLY VALVE
A t' KELLY
VALVE ACCESSBo% EFinish Grade
Finish Grade p
in
BACKWATER
VALVE
FLOW e7 FLOW A FLOW
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.