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LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
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TY OF CUPERTINO
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xo raA4_.� - Sanitary No.
0 � Da 196— Permit No
3 N�V _ tiiioO
Fee $
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0 Application is hereby made to t�,e City of Cupertino for a permit to install plumbing
`o w pipes and or tor�sI I everse side hereof, and agrees to install said prices
and rTfirctu in tst )d'Wejwit r the provisions of the Plumbing Code of the City of
Z w Cupertino, and all other laws applicable thereto.
a Use of Premises h A h M. S I N J<
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r 3 Owner _.A` M *A /V Address x-5-3 G
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, By U N t v 6Rja6- 5 PA PV X'S,64 Address b h-ib s �" S%— 5a
O CONTRACTOR, AGENT
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- Phone
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ao State License –1 Z Approve
— U PLUMBING INSPECTO /
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Si ze
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen 5ink 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
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Send Trap TOTAL, FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve I Water Sys.Fee
Relief Valve Gas 1'ee
Vac Breaker
Skimmer •
Filter
Permit Fee —
Total Total Fee ,u7