51037 111 401hw y� 64940�NO.
NO. STREET'
APPLICATION FOR PLUMBING PERMIT
z z a lrGa ITY OF CUPFRTINO
z 12
r 0 Sanitary N u.
O j ll, r 0 196— Permit No
3 47/0 -3
w Pee S (:
j LL
0 A l cat' is r t� he City of Cupertino for a permit to install plumbing
o a p�jj�s#d fix c� t 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 laws applicable thereto.
j ,. Use of Premises //�ilirvd�CP > 11'—1
00 /
' " LG aiJ fi ���s
0 3
Owner Address i.enr isn�
0J
z Address5
By 22/' 3J^
CONTRACTOR, AGENT
3r
— m Phone
w z
a ay ✓!S 3 3 3 Approv
State License,
U PLUMBING INSPECTOR
FIXI URES
UNITS FEES UNITS1 FEES
`%/atnr Hcate Size
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers size
Restaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee _ ,o 0
Area Drains f 1W Main Drain Fee
WEU —Leaders Storm Drain Fee
/ .—an Water Sys. Fee / r Q 0
/0' Permit Fee
TOTAL TOTAL FEE .
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough Complete
Main Drain
Final