691 LOT NO. `.
NO. STREET
y PPLICATION FOR PLUMBING PERMIT
OF CUPERTINO
Dat n `n. �n rt 195_ Permit No.
Lki I I� .Ivy ;_
ti Fee $
-v r n �1. r• � �
App datichols h�rc�j ala 7 J e.City of Cupertino for a permit to install plumbing
pipes and%or fixtures listed on the reverse side hereof, and agrees to install said prices
and/or fixtures'ih;accordance with the provisions of the Plumbing Code of the City of
s ' Cupertino, and�all othe laws applica ereto.
P Use of Premise
-- : . , ..
N Ownerd , k ,. Adcess*c'. d
By .. fm - Addroe,s• I ,
OA ACTOR, AGENT.y �J
_. Phone—fZ APproved
1+ PLUMBINGINSPECTOR J�
. FIXTURES • NUMBER MAIN DRAIN
. I UNITS I FEES II IUNITS1 FEES
Water Heater Size
Water Closets `-"►° Material
- _
Bath Tubs ',ndki'd,Curb
Showers .. 'IIr° ro Pmp. Line
Lavatories .✓zLi'To Existing
Kitchen Sinks ;.'7 +Not Conn.
Dish Washers II`SEWER E:oxes-�I
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines !'" Size _
WaterAofteners I; Material
Bar Sinks .r` To Main Drain
Comb. Sink &Trays To Curb
Dental.Units
Drinking Fountains)
Floor Drains WATER SYSTEIvtr
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
Urinals Fixture Fee .0
Area•,Drains ILII Main Drain Fee
r Water Leaders Storm Drain Fee
' S rinkler Vawes I I Water Sys. Fee
/ Permit Fee Uzi
TOTAL TOTAL FEE
RECORD OF INSPECTION
Partial Rough
Rough Com tete
Final o21j' n