51027.1 No. Street Lot No.
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E APP�lp Q�t L•I G } IT
�� CI Y OF CUPF$Tl O ,
0
H NOT 3 -L 1968 sa t, No.
m 196e Permit Nos
`� 7
Date C fiY OF CUPERTINO Fee $ �. �
3
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
in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
'c laws applicable thereto.
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ro U Use of Premises
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° Owner /J L_ --Y/ 1, Address59:—M�
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c Address OGG c Ga.
3 Contractor,Agent
73° Phone 5��0
G� �[ WILLIF.k7 D.
State License PG s TC� Approved
�7" Plumbing Inspector
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 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 =FixtumFce
Sand TrapFEES
Urinal 5OArea Drain eWaterLeader eeSprinklerystem
Relief V�1�� Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total 3 Total Fee