NO PERMIT NUMBER P,6rt,4L u E LOT NO. /G NO. STREET,
APPLICA� N� P�tl G PERMIT
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0 Date 196 Permit No
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3 0 �l r�/ �r !'I IOFPTIr!(� Pee S"�
Application is hereby m del to th Gay oRGu rtino fora permit to install plumbing
o 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
<w Cupertino, and all other laws applicable thereto.
,. Use of Premises S
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0 3 Owner�L(i A e«
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O CONTRACTOR, AGENT
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0o State License .1716Y;1Approved /
PLUMBING INSPECTOR �/
D XTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size 11
Water Closet Material e Z
Bath Tub % To Curb
Shower ,$d To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Q Size
Water Softener Material
Bar Sink To Mai a n
Comb.Sink&Tray T urb
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material d
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee SD
Vac Breaker
Skimmer
Filter
Permit Fee Db
Total I&F69CTotal Fee Qd