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`'� ���al CITY OF CUPERTINO
"w < 14AY 21 JWLICATION FOR PLUMBING PERMIT
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x o5nnita ry No.
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o � Date V4 � 197 / Permit No.
3a
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Fee $
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w w 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
> 1- 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.
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a Use of Premises
0 3 OwnerAF5 �A4441+16A Address 104YO AlAftE" ,Pj_
0 o I�l /(� Address9/0 �AKTNA
3Q CONTRACTOR, AGENT
— Phone 3 7" 27/ 3
W
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a o I titare License 27. 0387- ApprovedVVILLU-`M D. -NEVICH
U PLUMBING INSPECTOR /
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existin
Kitchen Sink Not Conn.
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.S ink&Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee i
Area Drain Main Drain Fee
Water Leader Stem Drain Fee
Sprinkler System Water Sys.Fee
Refief Valve / 11 Gas Fee _
Vac Breaker /
Skimmer
Filter /
Pool Sweeper /
Permit Fee
Total Total Fee /,