51113 C' 'n' LOT NO.
NO. STREET
APPLICATION ICATION FOR PLUMBING PERMIT
z< �,CI�OF CUPERTINO
rco , Sanitary N0.
° a Date /I �'/t' 196- Permit No. 5-1113
Sa
I'lr Fee $�
r ° Application is hereby,made'to the City of Cupertino for a permit to install Plumbing
o 1 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
a w Cupertino, and all other laws applicable thereto.
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�. Use of Premises
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Add cess 110o?6-/
r 3 Owner n. .S A Ol
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z By e`azll� Address
° CONTRACTOR, AGENT
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Phone
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u a State Licenseo2� 9��0 Approve
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U PLUMBING INSPECTOR
FIXTURES I NUMBER MAIN DRAIN
UNITS FEES 11 UNITS FEES
Water heater I Isiz—e
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen 5ink 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
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve / Gas Fee S o
Vac Breaker
Skimmer /
Filter
Permit Fee o2 vO
Total /o Total Fee J--a