51181I4z: ' / LOT NO
NO. STREET r
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
Sanitary No.
Date 196 Permit No
Fee
QoApplication is hereby made to the City of Cupertino for a permit to install plumbing
;PipesGand orffixtures'hsted A the reverse side hereof, and agrees to install said prices
'and/or fixtures ui a`ccordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other laws applicable thereto.
CUS?Yof "erPnir�•IPED—�;%� 7
Owner/Lll �D% Addresses
ByZ/� Address/
CONTRACTQ AGEtZlr
Phone
State License ���1�� Approved r{QI'�II-..F387�'s2V1C'rl
PLUMBING INSPECTOR �/
FIXTURES
NUMBER
MAIN DRAIN
UNITSI FEES
UNITS FEES
Water Heater
Size
Water Closet
Material O
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn.
Dish Washer
/
Sewer Box
Waste Disposal
Wash Tra "
STORM DRAINAGE
Washing Machine
Size
Water Softener
Material
Bar Sink
'I'a Main Drain
Comb.Sink & Tray
I'o Curb
Dental Unit
Drinking Fountain
Floor Drain
WA'T'ER SY TEM
Hopper
Size
Restaurant Sink
.Material
Sand Trap
TO'T'AL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee /
Relief Valve
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee 3 O0
Total
Total Fee