51231.1 k(D3 q \M OSS\ K LOT NO.
NO. ST EFI 1 10 II
CITY OF CUPERTINO
CRY OF eu'r;'X PLICATION FOR PLUMBING PERMIT
W 0 SEP 17
f Q 71— Sanitary 111.
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0 j Date -29 l9 lI Permit No
3
I P A I D Pee $ 33 fa
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� Application is hereby made to the Cit}' of Cupertino for a permit to install plumbing
01 pipes and/or fixtures listed on-the reverse side hereof, and agrees to install said prices
rI and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
wCupertino, and all other laws applicable thereto.
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�. Use of Premises ,- Rep C IC e In ( Q.
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0 3 Owner JY�h7 e-ll Address ,CiIAL !^ArC�
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O CONT ACTOR, AGENT
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0 d �C1 cOJ Approved VVILLIP—M D. B=NCVICH%
Q yo7 State License,
1 L 1/ PLUMBING INSPECTOR
FIXTURES INUMBER I MAIN DRAIN
Units Fees Units Fees
Water Heater I Size
Water Closet Z Material
Bath Tub f To Curb
Shower f To Prop. Line V
Lavatories To Existing
Kitchen Sink / 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
Restaurant Sink kFixture
al
Sand TrapOTAL FEES
Urinal Fee U
Area Drain rain FeeWater Lea er Drain Fee
Sprinkler System Sys. Fee
Relief Valve I Gas Fee
Vac Breaker
Skimmer
Filter
Pool Sweeper
Permit Fee
Total Total Fee