2136 �99�JS Ih RLT. Np19�/t. [1 pI LOT NO.
APPLICATICNCITJ FOR PLUMBING PERMIT
w z YJQF CUP•ERTINO
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3o a Dated a t` C?� Permit No
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O Application is hereby made to the City of Cupertino for a permit to install plumbing
o a pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
i N and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
0 0 Use of Premises
o a Own4dsr _ GLJ�1.wa, Address
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UNITS FEES UNITS FEES
Water Heater' Size
Water Closets Mecria;
Bath Tubs 2 To Curb
Showers To Prop. Line /
Lavatories To Existing
KitchZ!t -§lnks Not Conn.
Dish Washers Sewer Boxes
Waste„Disposals Z,
Wash,Trays STORM DRAINAGE
Washing Machines / Size
'sXrater!"Softeners Material
Bar Sinks, To Main Drain
Comb. $ink s Trays To Curb
Dental Units _
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks` Material
San Traps TOTAL ES
iUrinals Fixture Fee otO
iArea Drains Main Drain Fee Z
V_ -
Water Leaders Storm Drain Fee
Sprinkler Vnwcs ,r Water Sys. Fee oe
Permit Fee
TOTAL TOTAL FEE
RECORD OF INSPECTION
Underground Rough...
(Partial Rough..
Rough, Complete..
\Main Drain
;,Final...