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Lot No.
APPLICATION FOR PLUMBING PERMIT
CITY OF CUPERTINO
/971
IJ96--
Sanitary No.
Permit No..i_/i f.Z
Fee s 9 �a
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.
Use of Premises
Owner
By /v,U 7B•ds1 �Y
Con ractor, Agent
Phone
State License 14'14 179- c 53
Address
Address OS �i�iluea�%4
Approve
bmg Inspector
FIXTURES
NUMBER
MAIN DRAIN
Units Fees
Units Fees
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Non 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
Iio er
Size
Restaurant Sink
Material
Sand Tra
TOTAL FEES
Urinal
Fixture Fee
Area Drain
Main Drain Fee
Water Leader
Storm Drain Fee
Sprinkler System
Water Sys. Fee
Relief ValverGas
Fee
Vac Breaker
t
Skimmer
Filter
Permit Fee .2-
ZTotal
Total
7
Total Fee .ice