51114 S
NO. STREET
r-p , �AN PSI ATION FOR PLUMBING PERMIT
OF CUPERTINO $
./JUL 2
Date '91g 195_ Permit No.
o�
r ITY OFCUP Fee $
k,x) Application lNeUrlyNNde to the City of Cupertino for a permit to install plumbing
n 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
bZ( Cupertino, and all other laws applicable thereto.
Use of Premises 1 o 3 S'7 n e 1.1 N 1 S N
a
Owner P'A S t A KJ 1 cs N Address 10 3 5 IJ 4 4 nj t S p N
gy C 0, L /"p A N _ Address J $3 1` f_ , t. Q l P,
CONTRACTOR, AGENT
Phone 73G-PO O ff V Approve
PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Watcr Heater Size
Water Closets Material
Bath Tubs To Curb
Showers I To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish Washers
Waste Disposals _
Wash Trays STORM DRAINAGE
Washing Machines II Size
Water Softeners Material
Bar Sinks To Main Drain
Comb. Sink s Traysi I To Curb
Dental Units I I II
Drinking Fountainsi III
Floor Drains I I II WATER SYSTEM
ffo-ppersi Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
Urinals Fixture Fee / OD
Area Dr-a-insl 1 II Main Drain Fee
Water Leaders Storm Drain Fee
Sprinkler Vaives I II Water Sys. Fee
�I Permit Fee a,
TOTAL TOTAL FEE
RECORD OF INSPECTION
Partial Rough
Rough Complete
Final