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LOT NO. /✓�
NO. STREET'
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
// Sanitary No.
Date ��y— �Y' 196 Permit No
Pee $ 3 S%
lication is he eliy made to the City of Cupertino for a permit to install plumbing
idd%or fixtures4istell ythe reverse side hereof, and agrees to install said prices
`fixtures in accon
rdat' with the provisions of the Plumbing Code of the City of
me, and, all other laws' applicable thereto.
u I I ! 13bf
Use of Premises Y-', 0/ –
CITV J. r%tiiriiJL��t�/
Owner
CONTRA'TOR, AGENT
Phone
State License
Address Z
Address /a'4� O
Approved"LLIAM D• BENEVIcra
PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS I FEES UNITS I FF.FS
Shower
Kitchen Sink / \I
Not Conn.
Dish Washer /,
Sewer Box
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 S
Area Drain
I Main Drain Fee U O
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee
Relief Valve
I Gas Fee i SZ1
Permit Fee ol° 11
Total �J Total Fee o23. S
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