51182No. Street Lot No.
C" Of WpWIWO APPLICATION FOR PLUMBING PERMIT
APR
C 1971 CITY OF CUPERTINO
pp//�� J Sanitary No.
15ate* =S ,'196, %/ Permit No..i
Fee $ 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
in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
laws applicable thereto.
Use of Premises
Owner
By
Contractor, Agent
Phone
State License
Address/L�'t/– -Z 4001Y�
Address
Approve
Plumbing Inspector /
NUMBER
MAIN DRAIN
Units Fees
Units Fees
ater Heater
Size
ater Closet
Material
jFIXTURES
th Tub
To Curb
ower
'ro Pro . Linc
vatories
To Existing
tchen Sink
N.t 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
Sand Trap
TOTAL FEES
Urinal
Fixture Fee i S—�
Area Drain
Main Drain Fee
Water Leader
torm Drain Fee
Sprinkler System
Water Sys. Fee
Gas Fee
Vac Breaker
f
Skimmer
Filter
Permit Fee
Total
7 ,�
Total Fee T°