26120 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOIL6Iu-ECECTRICAI, PERkurNO.
APPLICATION/PERMIT - PLUMBING-MECHANICAL 26120
BUILDING DIVISION - - IIUILDING PROJECT IDENTIFICATION '-
BUILDING ADDRESS: /I / SANITARY NO. APPLICATION SUBMITTAL DATE
2,L&LO 1 cav, l0 1� L UNIT# LOT'#
OWNERS NAME: 5 HONE: CONTE CfOR'S NAME: /^1 LIC NO:
ne✓� u r o r
✓V N/C CONT OL#
RCHITECT/ENGINEER: LIC NO: ADDRESS:
z2 r✓e G� IN C- o/vo 6 3 ❑
CONTACT: I PHONE: ' re ➢ '
QTY. ELBQTRIC PBRMD y p SPEP BUILDING PERMIT INTO'-
' 0 a" a BLDG ELECT PLUMB MECH
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION APPLIANCES-RESIDF,N'LIAL JOB DESCRIPTION
Matz Ihereby affirm that l am licensed under provisions ofC1i 9(commeeingwi0t ('
JD OO9cedion"1000)of Division]of the Business and ProRssluns Code.and my license is In PANELS
OF full fore and effect.
�' oe1En.e e .. cow rkact�'2 10/9 o Earth AMPS
Z PX
O y Z'Z ARCHITECTS DECLARATION OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O Z,C I understand my plans shall be used as public records. _
<=LL SIGNS ELECTRICAL r" 1�I II'�\1eI
HH9 Licensul Professional OWNER-BUILDER DECLARATION SP ECIALCIRCUIT/MISC.
pxpi�,, C F 1 hereby affirm that 1 am exempt Bnm the Commences License Law for the _ p�
LLm following reason.(Sermon7031.5,Business and professions Code:Any city or county TEMP.METER OR POLGI T.` IFI
which manna,a permit fo concoct,site,,improv,,demolish,m repair any s[,.alone
�Y + pno,mit,issuance,also requires the applicant for such pumiuo file eelgned.warmer POWER )EVICES
W o�'q0 that he is licensed pursuantm the p...ideare Oc Contractor's L.".. lsw(Chapter
a 9(commercin with Section 9000 f Division 3 ofthe Business and Professions Code SWIMMING POOLE +CTRIC
o (commercial, )o ) VALUATION
_,y or that he is exempt merefam sod the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-IOXTURES
4 Section 9031.5 by wry applicant for a Permit subjects the applicant to a civil penalty of _
not more than Eve hundred dollars($500). NEW RESIDENTIAL ELF;CTR SQ.FT.
04m ❑ I,asowrmreftheproperty,mmyemployeeswithwagesas Neirsolecompensation, STORIES TYPE CONSTRUCTION
will do[lie work,and the structure is not intendedmorfered for sale(Sec. Business
and Professions Cede:The Comeacmfs License Law does not apply to an owner of
property whobuildsorimpmvesthereon,and w0doessuchwork himselforthrough his OCC GROUP RES.UNITS
ownempl,yees,pr,videdthat.uchimpmvememsamn,tintendeduroffemd forsale.If,
however,the buildingorimprovement is sold within ane year ofcompletion,the owner- 'TOTAL:
builder will have the burden of proving that he diL not build or improve for purpo f
sl"). y, .-PLUMBING I ERMI'C' c i:PEE FLOOD ZONE APN
❑ Las he ,,cutpropartyH,Business nc rofindn;Codec)Th wntracm.ts
onsvuetthe ossmt Ed 9044 Busmen.and ywhol ild Calc)The Contractors
License),awdfrsuchat ppiymnwant as muntimrty wM1nsed pursuant
Into, ontracorA PERMII'ISSUANCE
wh,c,mraw.for such pmJwb elm s,,n0aemr(sj licensed pursonnuodheConrmemde ALTER EA
Lice.,Law. ( ) FBE SUMMARY
❑ I nm exempt under Sec. ,B&P C for this reason BACK FLOW PROTECT.DEVICEOUTSIO FEES
SANITARY Y N
Owner Dam DRAINS-FLOOR,ROOF,AREA,COND. RECEIVI'#
WORKMAN COMPENSATION DECLARATION SCHOOL TAX YN
❑ Thereby affirm thmlhaveacedifieum rfconaent to selfinsme,,racenifcam of FIXTURES-PERI'RAP RECEIPT'#
Workera'Compwssrion Insurance ora ceetlEed copy mwwf(Sw.3800.Leb CJ which PARK FEE Y N
covers all employee's under this pemtit. GAS-EA.SYSTEM-1 INC. OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
Company
❑ Codified copy is hereby famished. GAS-EA.SYSTEM-OVER 4(EA) PLANCHFE
LCK E
❑ Cerifed copy is filed with the city inspection division GREASWINDUSTRL WASTE INTERCEPTOR GRADING FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP SOILS FEE
COMPENSATION INSURANCE
(This section need nut be completed ifthr,court is farrow hundred dollars($IW) SEWER-SANITARY-STORM EA.200FT. ENERGY PEE
less.)
i I acetify that nods,peffoonanceofthe work for which this permit is issued,Isbell WATER HEATER W/VENT/ELECIR
not employ any person in any manner so as to become subject to the Workers' PAID
Comparison.Laws of California. Data WATER SYSTEM/1'REATING Dare Receipt#
Applicant I
O NOTICE TO APPLICANT`.ILafler making this Certiorari of Exemption,you should NEW RESIDENTIAL PLMIL SQ.FI'. TOTAL:
t•-t ti beemara mbjecrm the Workers Compenmfirn Provide.,ofthe labor Code,you..in
tan" , fnfmwim emnpiy with such pwwak em this perob.hali be deemedrevoked. BUILDING FEE
Q CONSTRUCTION LENDING AGENCY SEISMIC FEE
Zhereby affirm that there is a construction lending agency for the performance of TOTAL: ELECTRIC FEE
U O the work for which this permit is issued(Sec.3099,Civ.C.)
Lenders Name PLUMBING FEE
F Lea I Address Q'I'Y. MECHANICAL PERMIT` FEE U 1.I aly that I have read his city
an county
and eine mat an aMve ammmanng is
cutlet.lagrwmcomply
and hereby lmtyandcepresntativeof and state laws relaun,m PERMIT ISSUANCE MECHANICALFEL
Uj
building e,nsruodi,gart hereby authorize duce of this city mercer upon CONSTRUCTION TAX
U above-mentionedpsave, for inspersion proposes. ALTER OR ADU TO MECII.
(Wed agree to siva,Indemnify and keep harmlea.y City of,agau tragainst
' Iinbili0es,judgmems,costs nndexpenses which may in any wayaccrve against said City AIR HANDLING UNIT(TO 10,0100 CPM)
moonscape", of,¢,rami u aN a.
gnal2 Q AIR HANDLING UNIT(OVER 10,000 CFM)
Siure of Economical J Dat EXHAUST HOOD(W/DUCT)
PAID
Ap
HAZARDOUS MATERIALS DISCLOSURq HEATING UNIT(TO ROOM BTU) Data Recelpn#
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(OVER 100,000 BTU) T �
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Gale,Swtl,n 25532(np
❑Yes 11 No VENTILATION FAN(SINGLE REMO) '
ISSUANCE DATE
p� p '
Will the applicant orfmurehuildingoecupennuse equipmeBOILER-COMP(311P OR 100.000 BTU)
ndordavicee which emit r P9 \`
kardous air conmminants as definW by the Bay Area Air Quality Management BOILER-COMP(OVER Em,co0 BTU)
411,mic'? 11 Yes AI
(J
Yes No NEW RESIDENTIAL MECH. SQ.1r. MAR � 9 1994
1 have rami the hazard,,manorial,rNm emems under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand Out CI 1 Y ut-
if me building docs not currently have.tenet,that it is my responsibility to notify the VUI'CPI I
occupant of the reanimmems which must be met prim to Issuance of a Certificate of
Occupancy.
Owner m authorized agent Data TOTAL: ISSUED BY:�
OFFICE
wa-w,T ..->pa:c•rwrs•...a. ,�,,. �.� � <=' , `N�ssa�•9^gv:F Twy�' P"m n+3 a;' v'nfi�l�*-�r'^,+urti+.�r`v.%+r'"•vi
PERMIT P-15337
CUPERTINO SANITARY DISTRICT
...r.11, I I .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.: BookPage B Parcel O O��j ." Date
1 Property Owner: 6 ,e vt A,/4 S . 6 u r d OTT r -e
Mailing Address:
(if different) t
Telephone:
Sirs:
(I/We), being the owner(s) (owner's agent),_hereby make application for connection of the property at:
C.4-4,'G2 & 20 RrQ.y�4 Roc, Coy lg-C4, � H O
consisting of the,following TYPE OF BUILDING(S):
Residential:. Single Family 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).-
3. To acquire a Plumbing Permit from the._Gt of _��2G�t_ �^ O , Building Department and obtain
inspection and approval by said'Building Departme 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 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 BACKFLOW Protective Device shall be installed on the above property by the owner. Type of device and installation
UD-shall comply with the Plumbing Code Requirements of the jurisdiction shown in 3 above.
FEES:
Connection Permit Fee: $
Sewer Service charges to June 30, 1914--,s ../mo.x 4 mo.: $
Inspection Fee for backflow protection device: $ 5�
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.
• ,,. itis � �/j/ � �
Acknowledgment:
Owner's Agent:
(print name)
,II SO
Receipt of$ ff 3 acknowledged and permit granted.
MARK THOMAS&CO., INC., District Ma ger-Englneer
by:
Note:See Details on other side of this permit.
1 ,
O
TYPICAL CLEANOUT FOR LATERAL, SEWER
Distance from Property Line
to be as close as practicable,
a, not to exceed five(5') feet.
c
J Lit.
• °Removable Cleanout Plug
n
0
a 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 I ,
Adaptor coupling
—�- FLOW m
Lateral Sewer I House Sewer
lateral Sewer slope House Sewer slope
determined by District determined by building deportment
—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. ..
c
TYPICAL BACKFLOW PROTECTIVE
DEVICE INSTALLATION
TYPICAL BACKWATER VALVE TYPICAL KELLY VALVE INSTALLATIONS
INSTALLATION - Juriv aiclional Rulrinions
Accepted By All Jurisdictions
FIGURE I FIGURE 2 FIGURE 3
metalled said.Brad. Installed Balm,Grade Installed Above Grad.
Shashi B.twun Steel Right-ol-Woy and Building Shashi At Property Lina Cleanout Shown Adjacent To Building
Requires Regular Malntenance i Require.Minimum Maintenance Racuiras Minimum Maintenance
Valv.T.Be R.movable Valva Should B.Remavabl.
> VALVE ACCESS BOX FINISH FLOOR
w
.Ilh/V.nLd Core.
p L v l a FINISH FLOOR KELLY VALVE
JKEi.LY
Inish Grad.VALVE ACCESS BO% VALVEFinish Grad.Finish Grade
f
� n
BACKWATER
VALVE
FLOW cl FLOw FSA/
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.
x�' 1