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,rAPP.LICATION, FOR PLUMBING PERMIT
CITY OF CUPERTINO
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1967 1 Sanitary No.
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Date ' ,DE'C /i 196 Permit No
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ApPlicationtis hereby inadeTto the 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 G7
Own + a Address -lt�-�
By4;� rQ1JEO /C,6�17 Addressco�-G%�
CONTRACTOR, AGENT
Phone a5 3—'90!7
State License a3cl`�13 J Approved WILLIAM D. BENEVICH
PLUMBIN9NSPECCOR /
FIXTURES I NUMBER MAIN DRAIN
UNITS I FEES UNITS I FEES
Water Closet 7
Material
Bath Tub
To Curb
Shower /
To Prop. Line
Lavatories
To Existing
Kitchen ink
Not Conn.
Dish Washer
Sewer Box
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinkin Fountain
Floor Drain
WATER SYSTEM
Hopper
Size
Restaurant Sink
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee 1161, FV
Area Drain
Main Drain Fee —Od
Water Leader
Storm Drain Fee
Sprinkler Valve
Waters s. Fee -7
Relief Valve
Gas Fee '.�7J
Vac Breaker
Skimmer
Filter
1 11 Permit Fee ,2 O O
Total 17Total Fee 1 / Sp