51117 / /ba kwociO Dal'j C LOT NO.
NO. F.T
AP ATION FOR PLUMBING PERMIT
CITE" OF CUPERTINO
w ¢ (( Q
P O � ',)�ai�� ��� San lta ry No. -49
R 9a .51/17
0 ate 9 Permit o
3 16— N
�P�
c� Fees 12.00
`6
App ica a ereby made to the City of Cupertino for a permit to install plumbing
o a pipes d/fixtures listed on the reverse side hereof, and agrees to install said prices
> ancj.,hiWxtures in accordance with the provisions of the Plumbing Code of the City of
a w Cul ino, and all /other laws applicable thereto.
.. Use of Premises •r1
00 /
o0Owner f`i pmt - Address cit, Z -L ire lis o.y Dr
<
o By Address
3 r CONTRACTOR, AGENT
- < Phone 2 5 2 - 9i� g 2-
z
g-Ar-70 /
rc a
< o Srnte License &6W Approved �
LUAIBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
Units Fees lUnits Fees
Water Heater Size
Water Closet / O Material
i Bath Tub O To Curb /
Shower To Prom Line -
Z
Lavatories 2 To Ex'
Itchen Sink n
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink&Tray To
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size UML
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee I J50
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Relief Valve 1 Gas Fee
Vac Breaker
Skimmer
Filter
Pool Sweeper
Permit Fee Z. 0 O
Total Total Fee