51123 No. Street Lot No.
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a.) PPLICATION FOR PLUMBING PERMIT
E a IN ' CITY OF CUPERTINO
0 1
Sanitary No.
nOCT 22 , 196 C Permit N0511
Y Date
0 Fee S 9, 1�
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,-and-agrees-to-install-said-prices and/or fixtures - -
0 in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
2 laws applicable theret
0
Use of Premises
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0' ° Owner A.<'G/A AddresszOO�z y' ' vC
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v, By1114--7/ OOGf Addressq/41j;W/Y 'oW'z0 A0
3 r Contractor,Agent
0 Phone 32 - 2 712 jib
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;y State License 2203? Z Appro
�1- 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 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 '7. 3—v
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys.Fee
Relief Valve, C.2s Fee,
Vac Breaker ✓
Skimmer we
Filter ✓
Permit Fee
Total ,S Total Fee 3�