NO PERMIT NUMBER (3) No. Street Lot No.fib'_
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v APPLICATION FOR PLUMBING PERMIT
E CITY
ITY -t�tPE O
"an No.
Y Date / - - .(� 14 1968 Permit No.
° Fee S7'i O •
3
Application is hereby made�fo'ft q C�ty�of r a permit to install plumbing pipes
and/or fixtures listed on the Mverse sidd riere s� r�tall said prices and/or fixtures
,; in accordance with the provisions of the Plumbing Code of t e ity of Cupertino,and all other
laws applicable thereto.
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A � Use of Premises / cc!!
o ° Owner .�/�G.� �7'EG% Addresy- 7��C�liS/lBl✓H
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By Address
3 Contractor,Agent
W ° Phone asa- 9o9r
3
n
- -?; State License Approved
•�j- 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 Existing
Kitchen Sink Not 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
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief V.1ye 11 Ca%Fee
Vac Breaker
Skimmer
Filter
o C '
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r
Permit Fee
Total Total Fee