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No. Street Lot No.
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v C5V'OF APPLICATION FOR PLUMBING PERMIT
E CITY OF CUPERTINO
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Sanitary No.
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0 , 196_ Permit No/�.2 9
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3 Fee$_7
s 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
o in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
laws applicable there
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A n Use of Premises
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o Owner .>•/ A ss
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__ rn By' Address
C tractor,Agent
° Phone 1! �2
State License 607f-r-t f-tA >c.ciyf Approved
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 ink N t 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 G
Water Leader Storm Drain Fee
Sprinkler System Water Sys.Fee
Relief Valve
Vac Breaker
Skimmer
Filter
/ 6- 777 17
Permit Fee
Total Total Fee U
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