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No. Street Lot No.
`APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
�EC 6 1968 Sanitary No.
Date r -x — -- I96
1 — Permit No.
Fees K,JOL
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
in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
laws applicable thereto.
Use of Premises
Owner S,I.a
By
Q' Contractor, Agent
Phone . 2.�;- V -S PO
State License
Approve
Plumbing Inspector
FIXTURES NUMBER
Units Fees
Water Heater
Water Closet
Bath Tub
Shower
Lavatories
Kitchen in
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinking Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler System
Vac Breaker
Skimmer
Filter
Total
MAIN DRAIN
Units Fees
Size
Material
To Curb
To Prop. Line
To Existing
Not Conn.
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee
Main Drain Fee
Storm Drain Fee
Water Sys. Fee
Gas Fee
Permit Fee
Total Fee