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LOT NO,
FOR PLUMBING PERMIT
OF CUPERTINO
Sanitary No.
196�� Permit No - "J 5—
CITY HI SR WQ Pees sn'
Appli on i PeE} a the City of Cupertino for 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 i/4GOaV/e /'Z/Z/1) i9,11,19 6
Owner �//P Address
By 6� le " &?W Address
CONTRACTOR,AGENT
Acne I"
State Li
Approved
y1U-LL4N1 M 03—NEVICH
U PLUMBING INSPECTOR
FIXTURES I NUMBER MAIN DRAIN
UNITS FEES UNITS I FEES
Bath Tub /' To Curb
Shower To Pro]. Line
Not Conn.
Sewer Box
Comb.Sink&Tray I 11 To Curb
Floor Drain I 1 11 WATER SYSTEM I
Drain
fixture
Storm Drain Fee
elieI Valve Gas Fee
ac Breaker
Permit Fe
Total Fee