51231.1 ")!m
No. Street Lot No. P
CITY OF CUicRTINO
m APPLICATION FOR PLUMBING PERMIT
a S E P 2 1971 CITY OF CUPERTINO
v Sanitary No.
7 I� A I D li- .?� �L
E Date , 19 Permit No. S / .3/. i
° 1 Fee S �
3
s Application is hereby made to the City of 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
0 in accordance with the provisions of the Plumbing Code of the City of Cupertino.and all other
laws applicable thereto.
' o
v
:, ro Use of Premise. n
° U
° Owner Addres �
c ro
h By Address
3 Cont for,Agent
° Phone 0
3
State License � Appro�ed
64 Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet 3 Material
Bath Tub To Curb
Shower To ProD. Line
Lavatories To Existing
Kitchen 'n 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 ,Ala
Sand Trap TOTAL FEES
Urinal Fixture Fee O
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief Valve I Gas Fee
I .
Vac Breaker
Skimmer
Filter
Permit Fee q)
Total if 1k.50 Total Fee