51226V
TION FOR PLUMBING PERMIT
CITY OF CUPERTINO
Sanitary No.
Lot No. ; -J�
�p r(1-)-( 1J4 -P; ' I, 196_ Permit No.'f
t�4E 1 i:? ti
Fee $ W%�j
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
in accordance with the provisions of the Plumbing Code of the City of Cupertino, and all other
laws applicable thereto.
Use of Premises
By
Phone /� 401/y/ ^�-
State License/ 7; -WI Approved
lumbing Inspector
IX• (,c)uNT. OX g�. 31 61
FIXTURES NUMBER
Units Fees
Water Heater
Water Closet
Bath Tub
Shower
Lavatories
Kitchen Sink
Dish Washer
Waste Disposal
Wash Tray
Washing Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinking Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler System
Relief Valve,
Vac Breaker
Skimmer
Filter
Total
MAIN DRAIN
Units Fees
Size 41"',
Material
To Curb
To Prop. Line
To Exist n
N n
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee
Main Drain Fee
Storm.Drain Fee
Water Sys. Fee "L
Gas Fee, /J7
Permit Fee 10-0
Total Fee