51124 LOT NO.
NO, 3nmsT" T�
AP_P.L'ICATIONFOR LUMBING PERMIT
IOF CUPERTINO
x o /SFP 22 1966 �(�( . Sanitary No.
a 196 Permit N0
3 Dat
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4 CIT OF CUPERTINO Fee 5 ./- •CG
0 Application is hereby made to the City of Cupertino for a permit to install plumbing
01 pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
i m 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.
LL Use of Premises00
O < Own e Address . 'z A-iL�l
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o By 1�� Address
3 r- CONTRACTOR, AGENT
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a o ���,,,{{{.....State Licence Approved /
U `y P UMBING INSPECTOR t/
Ix I URES ;,
UNITS FEES UNITS FEES
Water Heate Size
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
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
Comb. Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
San Traps TOTAL FEES
1 i9ivyle- I� Fixture Fee �yt�
Area Drains Main Drain Fee
aC r' Storm Drain Fee
Sprinkler Valves Water Sys. Fee
Permit Fee
31, 00
TOTAL I TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final