2616 q. TR F.
APPLICA 1 FOR PLUMBING PERMIT
N QIQR 19641 OF CUPF.RTINO
wz
, W Sanitary No..
Q 4
o a Dat �,r+196— Permit No
W 4 - Fee $ //0
� 0
Application is hereby made to the City of Cupertino for a permit to install plumbing
o P 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
a w Cupertino, and all other laws, applicable thereto.
4 Use of Premises
00
3 Owne ,� Address
o a ell
0
Z J
B i j/���%? ddress
CONTRACTOR,AGENT ) '
w i Phoneme/ `
ww
¢ a Y' ��i'�!/`/ Approved Com/
a o State License
—U
PLUMBING INSPECTOR
11 ix I URES \ BER MAINDRAIN
UNITS FEES UNITS1 FEES
Water Heater /, Q Size
Water Closes16
71 Matera.GdL
Bath Tubs M Curb
Showers To Prop. Line
Lavatories gTo Existing
Kitchen Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines 1,1212 1 Size
Water Softeners Material
Bar'Sinks To Main Drain
Comb. Sink % Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size z
Restaurant Sinks I Material
San Traps TOTAL FEES
Urinals Fixture Fee /0�
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
�prmkler Naives Water Sys. Fee
Permit Fee
TOTAL / // TOTAL FEE
RECORD OF INSPECTION
Underground Rough...
.Partial Rnugh.. .yam—�
.Rough Complete..
\Iain Drain