51134 &y �Y9 I V� .XifC/ LOT NO.
NO. STREFU
d ?9-EA1� 0 OR PLUMBING PERMIT
CIFCUPF.RTINO
E 1���,,,,,,,II�����++ Sanitar Nu.
C 7 1968 Y3aUate �� 196 Permit No 'S���/`
Fee $ -r0
QTY' .a ��,?€ tie Q
� ° Apl � n � ereb e o tie ity of Cupertino for a permit to install plumbing
'o 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
Ln
Cupertino, and all other laws applicable thereto.
wx
r r
0 a Use of Premises �r
00
z0
Ownerti ;119& ce. /�X�-ex Address/G f�31 (hALd ri
z By ",/"/ iU2& t-6.tu .l. .�-t- Address->J��-�
O CONTRACTOR, AGENT
- m Phone )
State License �� Approved��
w
ww
¢ n
O¢ O F
U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existin
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray $'l'ORM DRAINAGE
Washing Machine $i ze
Nater Softener .5�. Material
Bar Sink " ' To Main Drain
Comb.Sink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap 'TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total �',s� Total Fee