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22657r • OZ ? O P N W W C CL D Z UO U. ~ Ow Ya F N Z U— C APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY Building Prom Identification PLRM1TNO. Building Address: o yi � � 22657_ nen ossa: one: .p(LNs. 2" 7- D%%/3 CITY OF CUPERTIN6BUILDING DIVISION APPLICATION / PERMIT BUILDING-E.ECTRICALPLUMBING-MECHANICAL A. A OO J t l Cent o CATEGORY CONTROL Itect/Engineer. Lie No: QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO Address: )?d4&701'elti� ^'� PFRMITISSUANCE El 1:1❑ LICENSED CONTRACTOR'S DECLARATION I herebyaffirenthat l am licensed under provisions of Chapter 9 tournment AKUANCF& tESIDENTIAL JOB DFSCRB'TION PANES ingwith SecUmn7000)of Dlvielon3ofthe Businessand ProfesslonsCode, and my License is in full fo d effect. Liana lace LI[.N Qp — ' /\� - e - t4 ,sekte-11 L� nate"Z%� cnmrann� UP TO 2DO ANTS mi-iOVE000AM15 ARCHITECT as uRAT1oN I understand my plans shall be used n public reconis OVER 10!10 AMT'S SQ. FI. FLOOR AREA 5/SQ. FT. SIGNS ELECTRICAL Licensed Professlonsl OWNER -BUILDER DECLARATION I hereby affirm thatI am exempt from the Contractor's License Law for the ' ALE D SPECIAL CIRCUIT/MISC UE(p METER OR POLE INST. ad following reason.(Section 7031 S, Business and Professions Code: Any city or county which requires permit to contract, alter, lmprove, demolish, or repair � /7 `\/� p T E any structure prior to its Issuance, also requires the a pplicant for such permit to file a signed statement that he 6 licensed pursuant to the provislorei of the (OWER DEVICES V SWDAMING POOL ELECTRIC Contractors License Law (Chapter 9(commencing with Section 7000)of Divi. sion3 ofthe Business and Professions Cods) orthat he is exempt therefromand r-- - the basis for the alleged exemption. Any violation of Section 70315 by any appllanl fora permit subjects the applicant to a civil penalty of not more than OUTLETS -SWITCHES -FIXTURES five hundred dollars %S0B. ❑I, as owner of the property, or my employees with wages as their sok NEW RESIDENTIAL ELECTRRf. STORIES TYPE CONSTRUCTION compensation will dothework, and thesaucture Is not intended or offered for .In (Ser. 7W4, Business and Profession Code: The Contractors Lice. Law does not apply to an owner of property who builds or improves thereon and who does such work himself or through hlsown employees, provided that such OCC. CROUP - RFS. UMTS TOTAL: Improvemenb am not Intended oroffer dformle. 1( however, thebullding or Improvement usoldwithinonyearofcompldll theowner-WiMerwlll have tht4urden of proving that he did not build or improve for purpose of sale.). 1-i L as owner of the property, am exclusively co tr.&I g with Licensed contracture to construct44, ct the project (Sec. 70Business and Profession Code: QTY. PLUMBING PERMIT FEE FLOOD WINE APN PERMIT ISSUANCE p O The Contractors Litt. Law does stat apply to an owner of property who Wild. or improves thereon, and who contracts for such ppcts lowith a ,JNdfTactor(s) licensed pursuant to the Contractors License Law. LI I am exempt under Sec. B & P C for this reason ALTER -DRAIN &VENT -WATER (EA) FEE SUMMARY BACK FLOW PROTECT. DEVICE F WS DRAINS FLOOR EDGE, AREA, GOND. SANITARY Y_ RECEIPT N�� Owner Date WORKMAN e. VcertificateSATION DECLARATION m�t to self -re, ora avhave acertificatete of comma ❑1 hereby a!llrm that I have certificate ofWorker?CompenaOon Insurance or a esniied copy thereof (Sec. 380D, lab CJ FD(TUES. PER IRAN SCHOOLTAX Y_ N_ RECEIPT N GAS FA. SYSTEM -1 INCA OUTLETS PARKFE Y N Poilryp Com env �nrxs- CASFA.SVS-EM-OVER4(EA) BUILDINGID VISION FEES r;�-arYY CenlRedmpylsherc tumisAed. Ceni(ied copy La(Iled with the city lnpecilon tlivislon. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE GRFASE7RAP CERTIFICATE OF EXEMPTION FROM WORKERS' PAID SEWFR.SANITARY-STORM EA 700FT Da J COMPENSATION INSURANCE (fhissenion need not W completed if the permit tattoucan hundred dollar Date Raclin t# WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_ (81 W)ne)css") I cenify that in the performance ofthe work forwhich this permit is gated, WATER SYSTEM/TREATING I shall not employ any person In any manner so as to become subject to the Workers'Con,mauon Laws of California. Date PAID NEWRFSIDENTIALPLMB. SQ.FT. Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'Comperss rtlon provision of the Labor Date Revel t# TOTAL: BUILDING FEE Codi, you most fort hwith comply with such provision or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE TOTAL:O ELECTRIC FEE I herebyafRrmthat there Lsamntructton lendingagency forlhe perform ante ofthe work forwhichihis permit is issued (Sec. W97,Cm.C.) lenders Name Lender's Address I certifythat I have mad this application and statethatthe above Information rct.I agree to comply with all city and county ordinances and state laws re PLUMBING FEE Q,OC QTY. MECHANICAL PERMIT FEE MECHANICALFEE PFRMITISSUANCE PEES PAID remtingtobuilding.ntt dion,endherebyauthorizempmwntattvesofthis city to enter upon the abovcmemiuned property for inspection purposes. (We) agree to save, Indemnify an d keep harmless the City of Cupertino against liabWties,judgments, cons and expenses which may in any way accrue ALTERORADDTOMECH. Date Receipt# AIR HA NDUNG UNIT (TO 10," CFM)' SUBTOTAL: said City in roneegyence o(the granting of this perm / AIRIiANDUNGUNT(OVFR10,000CFM) CONSTRUCTION TAX 4kenature of Applicant/Contractor C•Date EXHAUST ITOOD(W/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous HEATING UNIT (TO 100,000 BTU) Date Recei t# material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the Health and Safety Cade Section 75537(a)t ❑ Yes 1] No Will the applicant or boom building occupant use equipment or devices HEATING UNIT(OVER 100,001) BTU) TOTAL: U•cv VENTILATION FAN (SINGLE RESID) ISSUANCE DATE which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? Yes SF�juNo s regWrementsunder 5.95of havernla the ursderl BOILER -COMP (3HPOR 100,000 BTU) BOILER-COMP(OVER 100,000 BTU) the Si, ndChapter Code, Senium currently a t nan,that I understand that if the building does not arrcntly have atenanL that ltis; my understand that fifth & building have n,nponsibility, to notify the occupant of the requirements which most be met prior to Issuance of a Certificate of Occupancy. �ryr NEN RF5IDFN77AL MCCH. BQ.Ff/J ISSUED BY: "t%a�a'r l{y� ft, Owner or authorized agent Date TOTAL: OFFICE COPY UPERTINO SANITARY DISTRICT 20065 Stevens Creek -Blvd Building C Cupertino, California.95014 Phone (408) 253-7071 SERIAL t,,, SEWER CONNECTION PERMIT NO. P 15184 R.O.S./P.M./Tract//No... Lot No... ....... A.P.N. Bk..,,2. 4....... Pg...Par.4.'V).. Date.. A.U.9.U.5�.�.....:.�............... The undersigned, being the owner (or owner's agent) of the property located at........................................................ /.<...!.!.....or /I. .. .. .......D.r....1��.P !..r�............................................................ 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 atthelimits of any existing District easement. (Note — Detail J) 3) To acquire a permit from the ... (! � D .d..... �. j0ems!: —+ h.O.......................... Building Depart - ova • ment and obtain inspection and appr....I 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 .R-<�.!=!j<f' c` ..... C...'E't�).t7:�1.... Telephone ... z�.7...Q.`[.!._-� .................. Mailing address if different from above ....'��. G ..?m. e............................................................................................. By�........................................ I E]A standard backflow protective device shall be installed, to the satisfaction of the Building Department, for the above property. (Note — See Detail I) FEES: n � Connection Permit Fee G Sewer Service charges to June 30, 195). 7., $ ....,�.a .- ... /mo. X. 1. (.. mo. �............. . .f� Inspection Fee for backflow protection device TOTAL OReceipt of acknowledged and permit granted. MARK THOMAS & CO. INC., Dis rict Manager -Engineer By. .,�G. NOTE: See Details on other side of this permit. CUPERT/NO SANITARY DISTRICT NOTES: All volves to be accessible and maintained by Property Owner. Overflow point at least twelve inches(12") below lowest finished floor containing plumbing. Kelly Valve installed at Property Line to be readily removable for Lateral Sewer maintenance. Volvo Finish Grade Volvo Access Bbe - a with Vemad Cwar m E Valve Access Bos Backwater Vall Figure I Kellv Valve - Below Surface Installation -Shawn al required Property Line Cleanout. Kelly Valve Figure 2 Figure 3 Backwater Valve — Normally Kelly Valve - Above Ground installed al shallowest paint Installation -Shown installed along House Sewer between close to building. Property Line and building. g as . STANDARD BACKFLOW PROTECTIVE DEVICE INSTALLATION I DETAIL Distance from R to be as close as practicable. Removable Cleanout Plug A.j7UP6 Finish Grade Wye for Riser Cleanout Bos with Lid to be accessible Short lengthintained by property owner Adaptor coupling--� _ FLOW m minimum slope determined by Building Department. Lateral Sewer Cleanoul to be some size as Lateral Sewer. I I DETAIL I STANDARD CLEANOUT FOR LATERAL SEWER J