100022 100 .oJ v
LOT NO.
NO. STREET
APPLICATION OR PLUMBING PERMIT
CITY OF CUPERTINO
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LL _4 566 I I Sanitary Nu'
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O a U/a�teTT 1/1�-C3 196�i6 Permit NO
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Application is hereby m.defo>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
> I and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
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Cupertino, and a[ r laws applicable thereto.
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Use of Premise-
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1- 3Ownerlt S• �eI4�aL(b • Address
Dy y �g&UVj e/ Ge�y� 2861 Swar 1^'rrteCf
13•
z z Address
3 O CONTRACTOR, AGENT
— 0 Phone S1 ZSy-3 I Z,O • ^'V •�e>oG �R {-
ao State License)& 5-Z71;67 Approved
U /PLWIBING INSPECTOR
FIX I URES NUMBER
UNITS FEES UNITS FEES
Water Heate Size
Water Closets Material
Hath Tubs To Curb
Showers To Prop. Line
Laeurl�es" ego To Existing
Kitchen Sinks - Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
fiar-S+�ksTt�ys, r To Main Drain
Com
. Sink s Trays To Curb
Dental Units
Drinking Fountains
Moor Drains WATER SYSTEM
Hoppers Sine 4[r rjb
Rcstaurant Sinks Material
San Traps TOTAL FEES
Urinals Fixture Fee SS'b
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
9prinkler Volvos Water Sys. Fee
— / _
Y 1 3 Permit Fee .-60—
TOTAL
OTOTAL TOTAL FEE p
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final