51140 W�o
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a APPLICATION.FOR'+,PLUMBING PERMIT
E Cf[TYOF'CUP_ERTINIO� ��,'"
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J DEC ` Sanita�ry, No.
E Date ^'—, 196e � 1968 Permit No.sm/y
Fee$
Application is hereby made to the City of Cu erfino_Cor a-permit to instal] plumbing pipes
w and/or fixtures listed on the reverse side hereof,and agrees to,install said prices and/or fixtures
in accordance-with-the-provisions ofthe Plumbing Code of-the City-ofCupertino,-and-all other -
'2 laws applicable thereto.
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A ro Use of Premises
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° Owner Address SJ .
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Address
3 Contractor,Agent
e ° Phone _�'2'?^ .2 //o
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a , teaState License 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
KitchenSink Nol C nn.
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 Ga�Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee