51114 ar 16:::, e LJ � LOT NO.
NO. S"E.E.T
IGjATIOtN FOR PLUMBING PERMIT
d rY OF CUPERTINO
w z I11ll1 �I
2 1, Sanitary No.
o a Date J� � 1P J 19617 - Permit No
ee SC+pn ` UJb�RaT[ he City of Cupertino no foraPermit to install plumbing
(�\'o 1- pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
y' \> a and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a) Cupertino, and all other laws applicable thereto.
U
Use of Premises
00 p /
3
Owner— iS��� Addresszj
Ji z $y ll/OA Od Address
°_ COIJ—TALA^�CTOR, AGENT
Phone //
z 9
State License. /0 / Approved /
a ✓/
U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Healer Size
Water Closet Material
Bath 'rub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
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 Si ze
Restaurant Sink Material
Sand Trap TO'T'AL FEES
Urinal Fixture Fee OU
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter 5
+ S
Permit Fee pad
Total Total Fee r p0