51161/dG11/ ���-' ' Ca LOT NO. /
NO. ST EE.I'
_-. ,APPLICATION FOR PLUMBING PERMIT
vi <` — P'J (MI 'N OF CUPF.RTINO
eSEP 25 1967 sanitary No.
o a Date 196— Permit No
t Pee $� D�
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A * licatiA2is herebyl made td the Cit}' of Cupertino for a permit to install plumbing
'o 1- pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws plicable thereto.
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a Use of Premises
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3 Owner Address)
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,By Lem Address
O CONTRACTOR,AGENT
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— am Phone
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f tate License Approved
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0 PLUMBING INSPECTOR Y
FIXTURES
NUMBER MAIN DRAIN
UNrrS 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
Sewer Box
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
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler Valve
Water Sys. Fee
Relief Valve
Gas Fee
Vac Breaker
Filter
Total Fee