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NO. STA l
APPLICATION FOR PLUMBING
"•� 1 �,��_•,� I�CIT'Y'OP CUPERTINO
PERMIT
�tY,C^�' h .'; ' Sanitary No.
Date 5 1967 196,Z Permit No `5r_X_z671/Pee S2
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Application lsiher�by ?ma��t3the"City of Cupertino fora permit to install plumbing
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
Cupertino, and all other layj applicable thereto.
Use of Premises
OW
B
CONTRACTOR, AGENT'
Phone �01�
State License. A���>9
Address
A dress
T
� , W T T_.n _ _'.I
PLUMBING INSPECTOR
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
Drinking 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 pa
Stone Drain Fee
Water Sys. Fee
Gas Fee
Fee