2697 LOT NO.
NO Q S E
LION FOR PLUMBING PERMIT
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CITY OP CUPI RTINO
f � 17 1964 Sanitary No.
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o aDate i 196` Permit No
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� Application is hereby made to the City of Cupertino for a permit to install Plumbing
oQ pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
�. Use of Premises
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3 Owne Address �1D8d/!/)//1JCENESiEP S
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z Bj; rn,2i' v i/e, Address OD, f�07 i5d .SSI f/.—!9 Ge�fX'
O CONTRACTOR, AGENT
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— W Phone 99Y4-39K5i�
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ao State Licens _ Approved
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PLUMBING INSPECTOR
IX R : NUMBER IN UKAIN
UNITS FEES UNITS FEES
Water Heater �Q
Size
Water Closets 3 Material
Batb Tubs To Curb
Showers To Prop. Line
LavatoriesI To Existing
Kitchen Sinks / Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Comb. Sink % Trays To Curb
Dent,al'Units
Drinking Fountains
Floor Drains WATER SYSTEM I
Hoppers Size
Restaurant Sinks Material p
San Traps TOTAL FEES
Urinals Fixture Fee //QQ
Area Drains Main Drain Fee
Water Leaders Storm Drain Fee
Sprinkler Vaives Water Sys. Fee �0Q
Permit Fee
TOTAL TOTAL FEE
RECORD OFINSP T
Underground Rough..
.Partial Rough.. _ =
Rough. Complete..
'Iain Drain —
Pinal... r r