51016.1 ' o No. - Street Lot No.
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a +::.,-�,-, P TION FOR PLUMBING PERMIT
E a "'=°' CITY OF CUPERTINO
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DEC 7 191 o Sanitary No.
Date i�`� 1�0 Permit No.JW/6'
3 CITY OF CUPERTINO Fee 1�
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
in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
laws applicable thereto.
A o
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Use of Premises
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° 'Owner z 455:;.,7— Address�� ��
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o m By ,�Zt'� C.�jKe C—�/ /��66 . Address
3 s - 411Contractor, gen[ �� -� C'/ 1e
A Phone
State Licensee Approved
Plumbing Inspector /
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater % Size 1"
Water Closet 3 Material
Bath Tub - To Curb
Shower Z To Prop. Line
Lavatories3 To Existing
KitchenSink / 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 L'
Sand Trap TOTAL FEES
Urinal Fixture Fee 1J�
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Relief Valve Fee
Sprinkler System Water Sys. Fee /
/S
Vac Breaker
Skimmer
Filter
Permit Fee
Total .3 Total Fee