NO PERMIT NUMBER .ZC I LOT NO.
NO. STRE.E.I'
; //fR"PP1L C TION FOR PLUMBING PERMIT
In
i a E i/ GI-TY OF CUPF,RTINO
o �A°R 11 196B ,, Sanitary No.
0 a Date 196_ Permit No
�r Pees 9s
o " MWERTIN.0 �°
Application is hereby made to the City of Cupertino for a permit to install plumbing
o pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
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n Use of Premises
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Owners ED �rf�To N Address
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z By �G?�y/In+%iA/. y Address �2
Jo CONTRACTOR, AGENT
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– w Phone 4 —;7
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aw w � �3 S2 1Nfl_L!"i.i Z_, .MCH
o State License Approved
.—U PLUMBING INSPECTOR v
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FIXTURES NUMBER MAIN DRAIN
I1NIT5 FEES UNI'T'S FEES
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tra• STORM DRAINAGE
Washing Machine Size
Water Softener " ' '? Material
Bar Sink To Main Drain
Co`r.b.Sink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain 11 WA'T'ER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixtw'e Fee
Area Drain Main Drain Fee _
Water Leader Stolm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve I Gas Fee _ R!
Vac Breaker
Skimmer
Filter
Permit Fee ZL W
Total 'Total Fee J-6