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30211 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINQ BUILDING-ELECTRICAL PERMIT NO. 0 w BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1 BUILDING PROJECT IDENTIFICATION ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE o�D`/a5 s ;/ve.2 R O NAME: 110NE: CONTRACTOR'S NAME: LIC NO: O 9 DO U d ger NIC CONTROL# RCHITECT/ENGINEER: LIC NO, D R SS: El! // �ycdc�/c� �R• S J CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRAC'TOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby affirm Thal I am licensed under powmem,of Chapter 9(commencing ]OB DESCRIPTION WOO with Section 9000)of Division 3 of Bull near and Profession,Code,andmy license is RESIDENTIAL• FOO in fall force and effect. PERMIT ISSUANCE aUV License Class Lic# ❑SFDWL ❑KITCHEN REMODEL yZW Datc Contract., APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE ysego� ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT [_1 STRUCTURAL land andmyplan hallbeusedl,puMi records MODIFICATION O�FO c UPT0200AMPS ❑INTERIOR C1 CHIMNEY REPAIR E..� -t sed Professional 201-IINNIAMPS IMPROVEMENT �Y j OWNER-BUILDER DECLARATION OVER 1000A, C ly d I bunchy affirm that I into exempt from the Cotarvalm,License Law far the ❑BATH REMODEUREPAIR ❑DEMOLITION Gt�yC�3 d V following actor(Section 7031.5.Business and Profeseiom Code:Any city or a..ly SIGNS ELECTRICAL ❑OTHER W a a h which requires a permit to construct,alta,improve,demolish,or repair any structure F„oli O< prior to its issuance,also squire,the applicant for such pemtit to file a signed statement SPECIAL CIRCUIT/MISC. ppp d� that he is licenced pursuant to the provisions of the Contractor's License Law(Chapter 9 all 0 (commencing ando Sucrose Most,oCDivision 3ofthe Businessund Pmfusaions Code)or TEMP.MET ER OR POLE INST. COMMERCIAL- C, OMMERCIALL m that he is exempt therefrom and the basis for the alleged exemption Any violation of Section 7031 Sb any applicant for ❑NE BLDG/ADDITION El DEMOLITION y putnit subjects the applicant to penalty of POWER DEVICES Eo un ore than live huhe ndred TA ANT ❑FOOD SERVICE 04 t: l]Lash, stra addia,ettymmymoreeeswithwagesas their asa,70mpemvuon. SWIMMING POOL ELECTRIC PROVEML,NT p. will do the work,and thestrudure it..'imenJeJondfercd for sole(Sec."1044,Business ❑OTHER 3 m and Professions Code:The Contmmor4 License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon•and who does such work himself or through his we employees,provided that inch improvements are not intended car offend for NEW RESIDENTIAL ELECTS SOFT. sale,If,however.the building or improvement s cold within one year ofcompleti.ntbn SQ.HE FLOOR AREA $/SQ.IT owner builder will have the burden of proving that he did not build or improve for pur- ;pou oLsale.). ❑ I.as.wner'If the propmty,am exclusively contracting with licensed contmmors m TOTAL: nnstmet the project(See.9194,Bu sines and Professions Code,)The Catharines Li- cense Low does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE who contracts for such projects with a contmcmroo licensed pucmanuo the Contractors #� License Law. t T'• # T ❑1 am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE Owner ALTER-DRAIN&VENT-WATER(EA) Date n/ VA� TIO WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE VV I hereby affirm under Certify of perjury one of the following declarations: ❑ Ihave and will mvimvinaCenificnm o[Conswno ver-insure for Workersce of he DRAINS-FLOOR,ROOF,AREA,COST. work(r provided for by Section 3]00 of the Labor Cole,for the performance of the STORIES -'I//�(� TYPE CONSTRUCTION Y work..which thispcnmtls issued FIXTURES-PER TRAP ❑1 have and will ode,for Worker's ante oftle w Insurance,as require)by Seaton PUO oRhe Labor C.Ja.for thcprmnnceof the work for which this permit;;;sued. . GAS-EA.SYSTEM-I INC.4OUTLETS OCC GROUP APN My Workers Compensation Inmsnee unci,,and Policy number arc / Curtier: policy No.: CDa1 GAS-BA.SYSTEM-OVF,R4(EA) CERTIFICATE PEXEMPTION PROM WORKERS' COMPENSATION INSURANCE GREASF/1NDUSTRL WASTE INTERCEPTOR (This secJon need not bo mmplcted if the permit is Tomo.hundred dollua($I U BUILDING DIVISION FEES or leas) EASE RAP PLANCHECK F I cetlify that in the pafomtnnee of thework far which this permit is icned,l shill nm employ any person in any manner so os to bemvne wbject to the Workers'Compen- SOWER SANITARY-STORM EA.2(10 FT. ENERGY PEE 0 ,7, smion Laws of Culiforniv.Date ER HGTER WNENT/ELECfR Applicant z .. GRADING FEE h NOTICE TO APPLICANT:Ir,aper making thio Certificate of Exemption,you should WgTER SYSTEM?SEATING a;, hecomc xubjat 1.the Workers Compcnsaenn provisions of the LOM,Cede you mud SOILS PEE GI forthwith comply with such provisions nnhix permit shall he deemed revoked. WgTER SERVICE 0. Q az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID U I hereby affirm that there ix a construction lending agency forthcperfonnan a of Data Receipt# I, the work for which this permit;;is sued Xaa.3097,Civ.C.) Landers Name 'ate. W Lender's Address T TAL'. TOTAL: a, I certify that 1 have read this aWlieabun and state that the above into out a is BUILDING PEE Ch correct,correI agree to comply with all city and county ordinances and state Is ws relating m QTY_ MECHANICAL PERMIT Z building construction,and hereby authorize representatives of this city ,,emerup.,the FEE SEISMIC FEE ahrve-anummaed progeny for impaction puryoees PERMIT ISSUANCE (We)agree 1.save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE l iabil'nie,,judgmentc•costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) SOURCE REGULA IONS. MECHANICAL FEE r AIR HANDLING UNIT(OVER 11,000CFM) rgrotmoary App VContraam fJ CONSTRUCTION TAX Uate EXHAUST HOOD(W/DUCT) HAZARDOUS MNIERMLS DISCLOSURE HOUSING MITIGATION FEE Will the applicant or tutors building(occupant stove or handle hananfou,material HEATING UNIT(TO 100.000 BTU) as defined by the Cupertino Mare cipul Code,Chapter 9.12,and the Health and Safety Code.Section 25532m)! HEATING UNIT(OVER 100.000 BTU) ❑Yes E]No VENTILATION PAN(SINGLE.RESID) PAID Will the applicant or fumy building occupant use equipment of devices which Data Receipt# Part hazardous air contaminants ac defined byby the the BBay Arca Air Qmlity Mmvgement BOILER-COMP(3HP Ok 1 W,f100 BTU) District! ❑Yes E]No BOILER-COMP(OVER 100,000 BTU T I have read the hremder,material.,aquimare ,under Chapter 6.95 of the Cali- AIR CONDITIONER foto;.Health&Safety Code,Soames 25505.25533 and 25534.1 understood that if the ISSUANCE DATE building does not currently have a tenant,that it ism bili) to notifyfie occupant NEW RESIDENTIAL SUCH. SQ.HT- (if T of the requirements which must be met to issuance ofasCenfican,of Occu Pon prior Coney. Q Owner ur author¢ed agent Uatn TOTAL: '[ ISSUED BY OFFICE ! ' PERMIT P-15646 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. //400 Lot No. A.P.N.: Book 3/0 / Page 35 Parcel ✓T©� Date Property Owner: Rn i Pil C,t 4kG� �QM Mailing Address: Sc tM� (If different) Telephone: '777" 937 7 Sirs: (I/We), being the owner(s) (owner's agent), hereby//make application for connection of the property at: ne consisting of the fallowing 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 �i of L�AfiO'�1 np Building Department and obtain inspection and approval by said Building Department nor 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 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) 11-800-227-2600,--df least 48 hours prior to starting grading or digging operations. r SPECIAL PERMIT CONDITIONS(Exhibits): ❑ 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: G O Sewer Service charges to June 30, 19-i , $—LV!4 /MO.x Z mo.: 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: Owner's Agent: (print name) C Receipt of$ // 2 acknowledged and permit granted. MARK THOMAS&LCO/., INC., District Manager-Engineer by: � d ere-,/4— Note:See Details on other'side of this permit. TYPICAL CLEANOUT FOR LATERAL SEWER 19 Distance from Property Line to be as close as practicable, ou not to exceed five(5) feet. J m Removable Cleanout Plug n 0 a Finish Grade v. �.. 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 r - FLOW m Lateral Sewer House Sewer Latero) Sewer slope House Sewer slope determined by District o.Jdetermined 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. p TYPICAL BACKFLOW PROTECTIVE DEVICE INSTALLATION TYPICAL BACKWATER VALVE TYPICAL KELLY VALVE INSTALLATIONS INSTALLATION Jurisdictional Restrictions Accepted By All Jurisdictions e FIGURE I FIGURE 2 FIGURE 3 Installed Below Grade Installed Below Grade Installed Above Grade Shown Between Street Right-cf-Way and Building Shown At Property Line Cleanout shown Adjacent To Building Requires Regular Mainlenanee w Requires Minimum Maintenance Requires Minimum Maintenance it — Valve To Be Removable Valve Should Be Removable VALVE ACCESS BOX rcwith/Vented Cover FINISH FLOOR It Level at FINISH FLOOR KELLY VALVE rry f hiss Grade VALVE ACCESS BOX �rv''(RrIf KELLY VALVE Finish Grade Finish Grade i c n in BACNVE n VALVE FLOW Al FLOW LY FLOW Al Notes: 1. The Backflow protective device to be located on site in the house sewer. t 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. K a Kelly Valve is installed at Property Line, it is to be readily removable for Lateral Sewer Maintenance.