51140 roSCt6 t' 0
No. Street Lot No.
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v ® eta r C TION PLUMBING PERMIT
OF CUPERT
OF CUPERT[NO
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/QE e .� Sanitary No.
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s Permit N
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ee S a
Application is herb Ala
of Cupertino for a permit to install p tubing pipes
and/or fixtures listed on the reverse side hereof,an agrees to stall said prices an or fixtures
in accordance with the provisions of the Plumbing e of e ty of pertino,an all other
laws applicable t eto. S 4.% N�
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Use of Premises 1"VRw�pCQ ACf MQV�
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d Owner �_ Address KS 0:4�O.r2.
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By Address
3 Contractor,Agent
° Phone SS
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_ 1 M e H 4J%f Q Z Approved_._
State License`�
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 SinkNot 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
Refief V,lyp Gas Fee
Vac Breaker
Skimmer
Filter
NO N w.4 A"6r. 0 ILY 400V*ACTIOAP 7, F e..
OK AF-r&fk 9--iKt ALVA RfPLWgh,
-r Permit Fee 0
Total Total Fee
3 �