100236 .;2a
No. S Lot No.
o �
;, ® ICATION FOR PLUMBING PERMIT
i ' u CITY OF CUPERTINO
AN
Sanitary No.
E nl�I�yte(\� �' 196_ Permit No. O
(� I 1 vII ,S
3 Fee S�_
r 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
0 in accordance with the rovisions of the Plumbin7Cod t City of Cu r£ o, II other
laws applicable theret .
y
0
Use of Prem
_o U
° Oer • Add
o �
c m
__ w By Address
3 Contractor,Agent
° Phonc �
9
/S3 2 Approv
-u State License /
bing Inspector C/
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen ink 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 iL 0
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Lcader Storm Drain Fee
Sprinkler System Water Sys.Fee
Vac Breaker
Skimmer
Filt r
s
Permit Fee
Total Total Fee