51037f/ o 7 3 11"e e-7
F �
No. Street
D
APPL r
i1T
ITY OF CUPERTINO
I OCT 11 1968, N
q p am ry o.
Date �G MO
Lot No.
Permit No. S" C' j %
OF CUPERTI Fee S / S"
Application is hereby made to 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
Owner 621 • II �'��� �% Address &o,73 Ute A/Lt CT
By Address
ntractor, Agent
Phone 1.1 2 - L Fid
State
Approved ...._ .. ... _ .� .
Plumbing Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units
Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen in
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
S�
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
,ac Breaker
/
Skimmer
Filter
/
.)'wE c ESC
Permit Fee
-00
Total
,S
Total Fee
, .5—V