NO PERMIT NUMBER (2)LOT NO.
NO. STR)?fT
-. `rA_PPLICATION FOR PLUMBING PERMIT
(1ITY OF CUPERTINO
sR
0 i a rJSanitary No.
rc �t� ��C 167
o a Date , 1967 Permit No e,
i
Pee
o /T •-rT! I?— �• tnr� .., ..I
Applicatiomis'he(eb'}"rnade.to the.lCity of Cupertino for a permit to installplumbing
o W 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
< w Cupertino, and allother ws app licakle thereto.
w x
r
Use of Premises
0 3 Ow Addrest�`J
5
z B - Address L!�
O �/CO TRACTOR, AGENT
3 m Phone
aaState License Z�l'��%� Approved
_U PLUMBING INSPECTOR
FIXTURES
NUMBER
MAIN DRAIN
UNITS I FEES
IUNITS FEES
Water Heater
Size
Water Closet
Materia] /.
'Bath 'rub
To Curb
Shower
1, AIV
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn. '
Dish Washer
_
Sewer Box
Waste Disposal
Wash Tray
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
a
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 .:f rl
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee �( '
Relief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total
%f
Total Fee Ja