6140 No. Street ' Lot No.
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u APPLICATION'FOR=PLUMBINGPERMIT
E CITWOF CUPERTINO-
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H �Cly I /SSanitary No.' n
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x Date /^ 196�0!)r ,.Permit NC
Fee $
Application is hereby made to the City of Cupertino for,aiper_mit to install plumbing pipes
and/or fixtures listed on the reverse side hereof,and agrees to install said prices and/or fixtures
° A in accordance with the provisionsofthe Plumbing-Code-of the City-of-Cupertino,and all other
1.2 laws applicable thereto.
d
Use of Premises
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° Owner Address,/1053
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h By KCi Address 9
3 d Contractor,Agent
m ° Phone
-� State License
Approv
'f 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 i 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
Rel ef Valve 11 Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total To ee