51179NO.
LOT
7r� P
��P,PLI 'TION, FOR PLUMBING PERMIT
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CITY OF CUPERTINO
196-d'
y Sanitary No.
Date 'S�?' y 19611 Permit No
rnSt�tfi Fee $. 5
Apf&atibnei§'6rfby made totheCity 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
BY %/� T(
D v J I / 1,64 Ns —
6
CONTRACTOR, AGENT
Phone -
State License.
Address lj«+ r C /
Address TGy,T �-c'
Approve
PLUMBING INSPECTOR /
FIXTURES
NUMBER VAIN DRAIN
UNITS FEES UNITS FEES
Water Heater
Size
Water Closet
Material
Bath Tub
To Curb
Shower
To Prop. Line
Lavatories
To Existing
Kitchen 5ink
Not Conn.
Dish Washer
Sewer Box
Waste Disposal
Wash Tray
STORM DRAINAGE
Washin Machine
Size
Water Softener
Material
Bar Sink
To Main Drain
Comb.Sink&Tray
To Curb
Floor
\lain
Water Leader
Sprinkler Valve
Relief Valve
II[9LIF.UI
Permit Fee
Total Total Fee
ee