NO PERMIT NUMBER (2) LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
a QTY OF-CUPFRTINO
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25 1968 ��a': Fees lJ ••5 O
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� Application is hereby made to the City of Cupertino for a permit to install plumbing
'o a pipes and/or fixtures listed^ritT-the reverserside�her�eof,rand agrees to install said prices
i and/or fixtures in accordance with the provisions ofThe'Plumbing Code of the City of
a W Cupertino, and all r laws ape e thereto.
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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 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 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 Ljotal Fee .SU