51179/ O 19-5—
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NO. STRE F.a'
' AAPPLLIC�ATION FOR PLUMBING PERMIT
0ITY OF CUPERTINO
I,
I C Lv Sanitary No.
Uate 1961 Permit No 01 7f
('rr ''ryr \`n Pee 5 C/5-
`A'ppvat Dn is r`eb mad Ito Fele 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 in accordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other laws applicable thereto.
Use of Premises
Phone��'f'��6 D
State License
Address1b19.5��/I
Address �S�'
Approe WILLIAM D. BENZVICa /
L
PLUMBING INSPECTOR
FIXTURES NUMBER II MAIN DRAIN
UNITS FEES UNITS FFEES
Shower 1 1 II To hroD. Line
Waste
Not Conn.
Sewer Box
Size
Comb.Sink&'fray I 1 11 To Curb
Drinkin Fountain
Floor Drain WATER SYSTEM
fixture
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys. Fee
ee
Total Fee