100188No. Street Lot No. /
p )PPL CATION FOR PLUMBING PERMIT
KDEC
TY'OFCLIPERTINO
- 9 1968 Sanitary No.
Date (Z—./ , 196 Permit Ny�
A 1 Dd
J. 1 . OF
Application is hereby made tothe City± of Cupertino for a permit to installplumbingpipes
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
laws applicable thereto.
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Phone
State Licenso'no !� F/ Approve-
Plumbing Inspector
FIXTURES NUMBER
MAIN DRAIN
Units Fees
Units Fees
Water Healer
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn.
Dish Washer
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinking Fountain
Floor Drain
WATER SYSTEM
Hopper
Size
Restaurant Sink
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
Relief Valve
Gaq Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total
Total Fee