51181No. Street a Lot No.
° I
d APPLICATIO R UMBING PERMIT
CIY'Yr
CUPI?R?SI
E OF PL
0
6ttary No.
r y
Y Date 5F� 1968 ��„!jf Permit No.S//O
0 Fee S
3
_0^. Application is hereby made toyth _/ty &4j pvtWfortaIpermit to install plumbing pipes
— -- —and/or-fixtures listed-on thereverseside herebf�-arrr)-agAs to install -said-prices -and/or fixtures—
o in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
c 'c laws applicable thereto.
A
m
A n Use of Premises
0 Owner Addres
o �
ByAddress
Contractor, Agent
�•O Phone
3
n
State License _ Approve
�� Plumbing Inspector
FIXTURES NUMBER
MAIN DRAIN
Units Fees
Units
Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen Sink
Not Conn,
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
STORM DRAINAGE
size
Water Softener
Bar Sink
Material
To Main Drain
Comb.Sink & Tray
To Curb
Dental Unit IAL 1 11
Drinking Fountain t
Floor Drain
Hopper
I WATER SYSTEM
Size
Restaurant Sink I I
Sand Tra
I Material
TOTAL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
Relief Valve 1 11
Ca.% Fee
Vac Breaker t
Skimmer • At
Filter /APr
nl. /G
v ZZ
Permit Fee
00
TotalV //
Total Fee
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