51167 (2)///.3/ - f.4/os
No. Street Lot No.
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cm of cuvsint+o
v pp APPLICATION FOR PLUMBING PERMIT
fi AF -R1 n �nZ1 CITY OF CUPERTINO
o f� 1 O J
U Sanitary No.
�F Dat ' 1 Qee�Z — , 196 7 Permit No. 7
° 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
laws applicable thereto.
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An Use of Premises rs /
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o Owner �%/V/`1
14IrP t/ Ll n Address �l �3h
=� By 1-I/Ao Al i ` o o /S Address yt7(?rnrnp(,(/(�
Contractor, Agent
° Phone c�y - 7T S
3 / L 79 - CSS
A
--�- State License Approved.
Plumbing Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Pro . Linc
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
Material
Sand Trap
TOTAL FEES
Urinal
Fixture Fee 1 7�...
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
Relief Valve
11
Ga� Fee
Vac Breaker
I
Skimmer
/
Filter
/
r
Permit Fee
Total
Total Fee