51140D�3 p
No. S eet Lot No.S�2L
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o ,rte jp APPLICATION FOR PLUMBING PERMIT
E j � _ ��CITY OF CUPERTINO
�J 1 Sanitary No.
A �
Y Date �'eC-'� 3�C ', 196 Permit No.s1�1f0
3 ,._N, 00
vi ill�D�l?Tl�ln Fee 5
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r Application is hereby made ,to_the City of Cupertino for a permit to install plumbing pipes
and/or-fixtures-listed on the-reverse-side hereof,aneYagre s toinstallsaid-pri 'nd/or fixtures
; in accordance with the provisions, the Plumbing Cod f the City of C rti ,and all other
z.� laws applicable thereto.
A o
4
:, h Use of Premises Re4-a't'�t lK�"4
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° Owner /, L/ Address
Address
3 s Contractor,Agent
E ° Phone —� ��— .2 �/ 0 ar<—<"`z'"' W.0 0
� 3
��D 7�S-
- 2State License Approve
PH bing 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 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
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Re]Fcf Valve Ga.�Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee