51175Nn. STREET
LOT NO.
APPLICATION FOR PLUMBING PERMIT
�'-„s- CI1114196— OF CUPERTINO
—Sanitary No.
Date. /QCn c .� Permit No l5 7S�
i J'"Twi�€�'• Fee $ 27&
Applifati or; pis he{e4yy��ade to the City of Cupertino for a permit to install plumbing
pipes:.ind/ocJfjktuig�1j,Ed,3q'pjNiareverse side hereof, and agrees to install said prices
and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
Cupertino, and all other laws applicable thereto.
Use of Premises
Phone 3 �e /
State License� � O , '/e9%
Addredjolo t-/DG6o
Address
I
til
Approved//
PLUMBING INSPECTOR
FIXTURES I NUMBER MAIN DRAIN
UNITS1 FEES 11 UN ITS I FEES
Shower
Wash
Not Conn.
Sewer Box
Size
Comb.Sink&Tray I 1 11 To Cub
WATER
Size
urinal P fixture Hee
Area Drain Main Drain Fee S `�`
Water Leader Storm Drain Fee
Fee
11 Permit Fee
01 11 Total Fee