51038 /Oj ,x I _ /`+aR� LOT NO.
NO. STREET'
N Q AP�EI.{�A FOR PLUMBING PERMIT
JQ�g_. IT � CUPGRTINO
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0 < pate ( 967 � Permit No .f 000'0
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0 Appligsyigt�is hY by�lii�claQt '1�Sd[Ctif� of Cupertino for a permit to install plumbing
o a pipes an o ixt17Iist��J14)I l e r verse 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 haws applicable thereto.
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a Use of Premises
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3 Owner M S c'el Address /n 3 OG Fe)/'Q/1ru� (/Y
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ao State License Approved /
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PLUMBING INSPECTOR
FIXTURES N
UNITS FEES UNITSI FEES
Water Heate LMae
Wale, Closets rial
bath Tubs urb
Showers rop. Line
Lavatories xisting
Kitchen Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com .Sink v Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Tra s. ,y TOTAL FEES
Urinals .Sa Fixture Fee
Area Draire in Drain Fee
ZY�ater Leaders mm-flee _
Sprinkler V31Vl'5 Water Sys. Fee S9
Q� Permit Fee
TOTALI p TOTAL FEE 0 0
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final