Plumbing Application LOT NO/
NO. STREET
APPLICATIO� O RSL 1 BING PERMIT
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1 1968 Sa"t rNo.
0 a Date le / OC 192 Permit No /,��//
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(jr ('��?�.�TIS�O Fee $ 7"7. S�
LL 0 Application is hereby made+tq theClty 0f Cupertino for a permit to install plumbing
0 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
i w Cupertino, and all other laws applicable thereto.
Use of Premises
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Owner� k, Fe,,91VA, / //V IaEU &'Adless -ig/t/7fl CIZ94a
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O CONTRACTOR,AGENT
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— 0 Phone
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a a �3�52—rte Approve8V�1 t Inas n F.�NEVICH /
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`- -U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size C i _
Water Closet 4 Materiel
Bath Tub To Curb
Shower �... To Prop. Line
Lavatories To Existing
Kitchen §ink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine 2 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 j
Sand Trap TOTAL FEES .
Urinal Fixture Fee
Area Drain Main Drain Fee Oy
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee '—V
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total a 3 Total Fee