51001.3 P i a Y l I /", 12-i LOT NO. S
NO. STREET
--APPLICATION, FOR PLUMBING PERMIT
W d rl �- �� CITY OF CUPERTINO
s CC Sanitary Nu,
sis- 7
0 o Date I��C V ��/� Icf(i 47 Permit No L 3
O Application js,hereby made to'ttie City of Cupertino for a permit to install plumbing
`o a pipes'andfor 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
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Cupertino, and all other laws applicable thereto.
Use of Premises
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Address
Address
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3 F CONTRACCTOR, AGENT
— 0 Phon -J-d77
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a o State License o 121 Approved
Approved
PLUM
U BING INSPECTOR
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FIXTURES NUMBER MAIN DRAIN
UNITS1 FEES 11 UNITS FEES
Water Heater Size
Water Closet 3 Material
Bath Tub / To Curb
Shower / To Prop. Line
Lavatories .� To Existing
Kitchen ink / Not Conn.
Dish Washer Sewer Box
Waste Dispose
Wash TraySTORM DRAINAGE
WashingMachine / Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tray To Curb
Dental Unit
DrinkingFountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee DO
Area Drain Main Drain Fee •LR7
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee • J O
Total Total Fee D�