51016.1 c
No. Street Lot No.
o —
d QTY Of CUPRTOio APPLICATION FOR PLUMBING PERMIT
E CITY OF CUPERTINO
U APR 11911 Sanitary No.
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Y Dire �X — IYX/—
Permit No.
3 Fee$ 3i.o-o
t 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.
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m ro Use of Premises CT/.e-->[•SaiC lC
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° Owner C5S,-- LZ- A �T Address7�
By cC f. Address P
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3IV Contract gent ein• Afp'.PL<'y
V ° Phone,
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State License —_/ O .f/ O Approved
(d' Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet 3 Material C,T
Bath Tub Z To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen ink ' Not C nn.
Dish Washer
Waste Disposal
Wash Tray /, STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink URF
Comb.Sink&Tray
Dental Unit
Drinking Fountain
Floor Drain
Ho er Restaurant Sink Sand Tra> ES
Urinal Fixture Fee ...'L/.
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys, Fee
adief Valve Ga�Fee el
Vac Breaker
Skimmer
Filter
Permit Fee 2i
Total / Total Fee a