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30 a Dare -5 � 19�L Permit No z-
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� Application is hereby made to the City of Cupertino for a permit to install Plumbing
`o a 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 lawapplicabl thereto.
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FIXTURES NUMBER MAIN DRAIN
Units I Fees lunils Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower It To Prom Line
Lavatories 3 . To Existing
KFtche SinkZ19 Not 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 4Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee [j
Relief Valve I Ga,Fee
Vac Breaker
Skimmer
Filter
Pool SweepffEt.litFee
Fee ,df7
Total (�