NO PERMIT NUMBER (3) ILOT NO. /
NO. STREET
APPLICATION FOR PLUMBING PERMIT
z d CITY OF CUPERTINO
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x o �mi[ary No.
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o j Uate - - rmit No
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O Application is hereby made to the City of Cup for a permit to install plumbing
`o r pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
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and/or fixtures in ac� r�e �ry tI��p Q�[rr��rrf�gypp(( he Plumbi9 Code of the Cit A
a w Cupertino, and all otht4�l:lws4l �Iic4 tlheFhtbllV� s'Sj�Rg ,�Gc.reGC�IV
Use of Premises U
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3 Owner Address
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o By,MUIY�AIyfsfA �LG!/N�yi1k Address 0'41? />✓o
3 0 CONTRACTOR, AGENT
- < Phone
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� a 9�Z— Approved VJILL:A'- D.
�\ a o State License
CY—U PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater 11 Size
Water Closet Material
Bath 'rub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink 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
Restaurant Sink \1aterial
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water s.Fee
Relief Valve Cas Fee
Vac Breaker
Skimmer
Filter
Permit Fee aZ v-✓
Total Total Fee SZ1