1359 l 'G� /I �}`qV •®\ • ' \ Y'1 '\ v�� LOT NO.
' NO.
D 1 FOR PLUMBING PERMIT
!S►�iDEC- 181961 a'OF CUPERTINO
Date � , 195_ Permit No. �
CI 11/ OF C u
Fee $
Application is hereby made to the City of Cupertino for a permitt install plumbing
pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other ws applicable thereto.
Use of P--------
:4
em ses:a
41 Owners 1� Address
�!/ �y 'X Address
, / ONTRACTOR, AGENT
V Phone X -/337_ Approve f .Z
( PLUMBING INSPE
FIXTURES NUMBER 11 MAIN DRAIN
UNITS FEES II IUNITSI FEE
Water Heater 11 Size
Water Closets I : — II Material
Bath Tubs To Curb
Showers I / 0 To Prop. Line
Lavatories 2 �To Existing
Kitchen Sinks I II Not Coon.
Dish Washers
Waste Disposals
W$4Ti Trays I I STORM DRAINAGE
Washing Machines I I Size
Wates SoftenersI I Material
Bar Sinks T II To Main Drain I
Comb. Sink H Traysl I To Curb
Dental Units II 11 I�
Drinking Fountains) II
Floor Drains I WATER SYSTEM
Hoppers I II Sac II_
Restaurant Sinks I I Material
Sand Trups I TOTAL FEES !S
Urinals I I Fixture Fee
Area Drains I I Main Drain Fee h
Water Leaders Storm Drain Fee
Sprinkler VaivesI I Water Sys. Fee I ,�
Permit Fee uo
TOTAL TOTAL FEE
RECORD F INSPECTION
Partial Rough
Rough Complete
Final +� ney Z�
t , I, the undersigned do nerc�;y ce*tify that I am
the(owner and o cuppntof he single family dwelling at
for which I am making
a_:-plication to do work as a home owner.
I so certify th,rt I will not, hire an; non-licensed
ILM �r contracior, but will
/ddoo�this work myself.
TELEHONE .1 LifBE2 SIGNATURE .