100155 LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
d CITY OF CUPERTINO
z
r o Sanitary No.
� 4
o a Date 196_ Permit No /'C
3 Fee $ 3 J�
F�hpqp
l�icnt on i here6 made to the Cit of Cupertino for permit to install plumbing
Y P P P, g
o�� p sPanc�/o fixtures lsfed'on the reverse side hereof, and agrees to install said prices
ZiN /or fixtures in acArAoce with the provisions of the Plumbing Code of the Carty of
a upertmohand'Eall othaws applicable thereto.
w x
r r
to-"- YUse�of P emeses
'OTIT% E� rl � s
r Owner Add
3 ress
oa
zJ
z By X Address
O CONTRACTOR, AGENT
3 `
0 ?Sc3 976
— Phone•
w z
ao State License. Approved �..
-U PLUMBING INSPECTOR//
FIXTURES NUMBER MAIN DRAIN
UNITS I FEES I UNITS FEES
Water Ileater Isize
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen ink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink 'ro Main Drain
Comb.Sink&Tray To Curb
ffirmt
Unit
Fountain
rain WATER SYSTEM
Size
rant Sink Material
rap TOTAL FEES
Fixture Fee
rain Main Drain Fee
eader Storm Drain Fee
er Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee 1�