NO PERMIT NUMBER (2) e No. Street Lot No. /V
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APPLICATION-JORY 77 , IN�'P MIT
C_ro tCgp RP.tNdj DO,
��lociAaDate October Z , 196rmit No.
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CITY Fee s o2 G,
Application is hereby made to the City o/ perCSLJ[p7glrmlt�to S�
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
.� laws applicable thereto.
._
DHeIli g
_m m Use of Premises
.5: w ' Ditz Crane Company ?3ygSsDe La Cruz Boulevard
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� Owner
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rn By Palm Plumbing Company 1MsSunny4ale-Saratoga Rd.
3 Contractor,Agent
d ° Phone 245-2323
WiLLE::
— State License 186579 pproved
Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees I Units Fees
Water Heater / Size
Water Closet t3 Material rle
Bath Tub i To Curb
Shower To Prop. Line ✓
Lavatories To Existin
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 t 11-0
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief VAvp. I Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee 17V _
Total Total Fee