100176 )� �— LOT NO.
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LAPP. ICA I�N FOR PLUMBING PERMIT
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PITY OF CUPFRTINO
o TO 1968 J- � Sanitary \'o.
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o j Date �� �" 1965 Permit No /�0�(1
_ 0 n! ; V Or CUPERTINO Fee
0 Application is hereby made to the City of Cupertino for a permit to install plumbing
o 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 hof Premises
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3 Owner y �l Address2-
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zff Y Address
3 /Uv_amu„ '1'oR, ncGiJr
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Phone Z 3 L7
oState License x4� Approved
,�y U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FFEES UNITS FEES
Water Heater I % Size
Water Closet I Material
Bath Tub To Curb
Shower ( I To Prop. Line
Lavatories / S To Existing
Kitchen ink 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
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size 1 3A
Restaurant Sink Material lcc)efxl 1L0
Sand Trap TO'T'AL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee —
Sprinkler Valve Water Sys.Fee IS
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee 2
Total ° Total Fee