51069 1016 / 1 G„ e-�
NO. STNEE.I'
„ /`:7 APPLICATION FOR PLUMBING PERMIT
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CITY OF CUPP.RTINO
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Sanitary No.
o Date 196 Permit No
3a
Pee $
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Appheatihn isohereby made to the City of Cupertino for a permit to install plumbing
oa pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
r r and/or fixtures in a` rdance with the prow 'ons of the Plumbing Code of the City of
< Cupertino, and 0th r law nill able th ret .
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a Use of Premises
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,�. 3 Ownerl �/R �'`�"'�: Address
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Address xIM112d1:�'.�
3 CONTRACTOR, AGENT
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of State Licence Nzg sApproved D
a o r/
U I PLUMB NG INSPECTOR
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UNITS FEES UNITSI FEES
Water Heate Size
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
\Gash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Comb. Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FE
Urinals Fixture Fee CkaL
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
nrt cr V. v Water Sys. Fee
Permit Fee
TOTAL4 TOTAL FEE
RECORD OF INSPECTION
Underground Rough
Partial Rough
Rough. Complete
Main Drain
Final