NO PERMIT NUMBER (2) No. Street Lot No.
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a APPLICATIiQ)il,FO IBI RMIT
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Sanita .;
E Date October 28, 196$ UCT 31 1968 U P�em,it No.
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(� 3. s�
s Application is hereby made to the'City ditCCupert n�o�faratimi�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
n � laws applicable thereto.
0
A
Dwelling
F Use of Premises
oDitz Crane Company 2295 De La Cruz Boulevard
0
Owner Address
By Palm Plumbing Company 13dV&sSunnyvale-Saratoga Rd.
3 Contractor,Agent
Phone 245-2323
3 W ILLI�NI D. BSN:VICH
State License 186579 Approved �
KPlumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units I Fees I Units Fees
Water Heater / Size
Water Closet oy Material /
Bath Tub / To Curb
Shower To Prop. Line r/
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
j
To Main Drain
k &Tray To Curb
itFountainin WATER SYSTEM
Size
t Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys.Fee /SZ/
R�,Hof Vnl�e, 11 Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee a2 O
Total J: I Total Fee —7�3a-Z7