51167.1O.
LOT NO.
NSTR F. F.i' � �
IAPPLIC-AfTaION FOR PLUMBING PERMIT
CITY OF CUPERTINO _
�. Sanitary No. /(S
Date V
2 2 19671:362 Permit No.
Fee $ S—V
Ap- I—ior�rls her(F§' rMZS 'JYi thf)City of Cupertino for a permit to install plumbing
pipes ani3%Jor fi'Aures'litfeb'bn tiletreverse 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 aws applicable thereto.
Use of Premises
�7�
Owne/i.Gar�//e1. Address
n Ada ss f1 9
y CONTRACTOR, AGENT
Phonei5�3�'-�"'��
/?/G� NA LLIAM D. STNEVICH
State License 79 Approve
PLUMBING INSPECTOR
Y
FIXTURES NUMBER
' UNITS FEES
Water Heater
Water Closet
Bath Tub /
Shower /
Lavatories -3
Kitchen Sink /
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinkin Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler Valve
Relief Valve
Vac Breaker
Skimmer
Filter
Total
MAIN DRAIN
UNITS FEES
Size
Material
To Curb
To Prop. Line
To Existing
Not Conn.
Sewer Box
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
Gas Fee
Permit Fee
Total Fee d/jJ�