51179 (2)NO. STKE ET
P TI R PLUMBI
T 9 1UPERTINO
Samta
LOT
NG PERMIT
y IN o.
4 1967
Date � 19 Permit No —S--// % `1
([����TY ((��[[ ^�++ nt� Dp ,�.��rt Fee $� �.
ApplicaPt'UT. hcttgby t>tia@JP(ERcTY}Vtyf Cupertino for a 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 laws applicable thereto.
Use of Premises
OwnAddressZ�J
By1��L�� Address
CONTRACTOR,AGENT
State License
\� —0
Approvedb"'LYAH L. -
PLUMBING
. PLUMBING INSPECTOR
FIXTURES
NUMBER
MAIN DRAIN
UNITS FEES
UNITS FEES
Water Heater
Size
Water Closet
Material G�
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
Washin Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit
Drinking Fountain
Floor Drain
I WATER SYSTEM
Hopper
Size
Restaurant Sink
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee
Area Drain
.�-�)
Main Drain Fee ll ✓ v
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee
Relief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee p -U
Total
/Z
Total Fee