51187❑/ONo. Street Lot No.
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JUL 26 1971 APPLICATIONCITY OF CUPERTIING NO PERMIT
P Sanitary No. C
Date , 196[1 � Permit No. S/�O %
Fee $Qp
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. I 1
,
Use of Premises /n C,
Owner AIC/4 Adlh'AAA SfIA LL Address
n �9DS w�tiGHIS�UI
QY �`�y LYA� ��Ju�3 AddressACA.�r ✓dd[_s,
Contractor, Agent
Phone k 3T, -296c)
State License's � r1 / 2 1 Approved
Plumbing Inspector �-
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Pro . Line
Lavatories
To Existin
Kitchen Sink
MM 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
Hoper
Size
Restaurant Sink
Material
Sand Tra
TOTAL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
Vac Breaker
r
Skimmer
r
Filter
/
Permit Fee OIL
Total
Total Fee
9 s=