NO PERMIT NUMBER (3) LOT NO.
NO. Er
Q APPLIC O� G PERMIT
z T
Sa iTr \u.
octo f OCT 88 1968 .
o j Date 196— ermlt No
3�
LL g o? 3 ��
o Application is hereby 61.dTY, NWityiNOffCtu�@ alar a permit to install plumbing
`o pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
> a 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.
w x
Use of Premises Dwelling
° Ditz Crane C 22ppqq
3 Owner �Y 13d5ess I a Cruz Boulevard
oa
JJ fi Palm Plumbing Company ]A2 SSmuurvale-Saratoga Rd.
O y CONTAACTOA, AGENT
3 ` 245-2323
— 0 Phone
w Z
a0 ° 186579 ApprovedvI IAM D. CGENEV ICH
o State License n
1 . ri PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNI' S FEES
Water heater 11 Size
Water Closet o1-- Material
Bath Tub / To Curb
Shower / To Prop. Line r
Lavatories To Existing
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
Skimmer
Filter
Permit Fee
Total C Total Fee Ia3 5 J