51167.1/`� f I ���G/!E �. / ,L!fl/'i/ LOT NO.
NO. STItEEI'
AP_ROC�ee77TION FOR PLUMBING PERMIT
� CrI Y OP CUPERTINO
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x o i! I f ; Sanitary No. J,�//
Date/�' 196% 191116 Permit No �w Z /
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nl_ rI If? .p 'AI^ Pee $
Apphcatmn Is,hereby+ rnade.ItPTthesCity of Cupertino for a permit to Install plumbing
`o a pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
r 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.
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w Use of Premises
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< L2L,r.tl �i Address
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0 CONTRACTOR, AGENT
Phone�5�
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f State License s'�9 Approved•—y• �.�
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\I; — 0 PLUMBING INSPECTOR L11
_FIXTURES NUMBER �� MAIN DRAIN
llNITS FEES UNITS I FFFS
Bath Tub 11 To Curb
Shower 'T'o Prnn.
Kitchen ink Not Conn.
Dish Washer Sewer Box
Waste Disposal
1031131erl"m
WashiZMachine / �� Size
Water Softener Material
Comb.Sink&Tray I 1 11 To Curb
Fountain
_Floor D ain WATER SYS'T'EM
Hopper Size
1101,
MeaUrain Main llrain Fee '�--
Water Leader Stonn Drain Fee
Valve
Permit Fee
Total Fee