51177.1 (2).z
Lot No.
A5
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APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
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Q � ✓ Sanitary No.
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m Dat _ C71 , 196/ 0 Permit No,S// % %
o '(� r Fee 3 C P�
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s v�JApApplication 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
0 A in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
'c laws applicable thereto.
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A Use of Premises
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o Owner
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n By
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Address
02
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— --I(, State License ApprovedTLL'AM D. EMEVICH
l\^ Plumbing Inspector
FIXTURES NUMBER
Units Fees
WTub
ter
set
smer osal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinking Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
WFilter
A
/ O %
Total
MAIN DRAIN
Units Fees
Size
Material
To Curb
To Prop. Line
To Existing
Not Conn,
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee
Main Drain Fee
Storm Drain Fee
Water Sys. Fee
Gis Fee
Permit Fee
Total Fee