100255/ /O
c No. Street Lot No.
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n SEP L Q �91 APPLICATION FOR PLUMBING PERMIT
E CITY OF CUPERTINO
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Sanitary No. _
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E Date '—""r'` /b , 19�L Permit NI 0z -�'s
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3 Fee f-7 Ly
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
0 in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
laws applicable thereto. /
m m Use o(Premises
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0 Owner �7A2ot9 /T4o.t'Algx Address
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= ti By Address
3 Contractor,Agent
0 0 Phone 2S-.2- 2- '7 03
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4 i State License t""� Approved
D. F.'-n•^_....H
�el� Plumbing Inspector/ li
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater I Size v
Water Closet I Material CZ
Bath Tub To Curb
Shower To Pro . 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
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys.Fee
Refief Valve Ga.�Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee