51038 (2) No. Street Lot No.
o —
m CITY OF CUPEFTINO
E N1AR �9�I APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
0
P I D Sanitary No.
Y Date 196_ Permit No. S� d it
° Fee $
3
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
a'� laws applicable thereto.
Use of Premises
o_ V
v Owner /�—C. / Ve[--) Address ^7
c By T,/ �L M S 7 [-d Address .J.� '1 �V
3
Contractor,Agent /
° Phone
n 3
State License Approved
'Plumbing inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To P,.. Line
Lavatories To Existing
Itchen Sink Not Conn.
Dish Washer
Waste Dis oral
Wash Tra STORM DRAINAGE
Washin Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.S ink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Ho er Size
Restaurant Sink Material
Sand Tra TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief Valve Gas Fee
Vac Breaker f
Skimmer /
Filter
Permit Fee
Total Total Fee