2617 ' /4LOT NO.
ffMAWPL9-ATJRFOR PLUMBING PERMIT
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x o Sanitary No.
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3 a Date / caz4,.;+19674 Permit No. 1,4,1U l� [[I�'(( �F r1.t'
w 4 Pee $
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� Application is hereby made to the City of Cupertino for a permit to install plumbing
o a pipes and/or fixtures listed on the reverse side hereof, and agrees to install said prices
r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other aws ap icable thereto.
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Use of Premises /
00
3 Owner Address - . n
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3 t CONTRACTOR AGENT
— Phone
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< o State License . Approved
r PLUMBING INSPECTOR
FIXTURES JBER MAIN DRAITT_
UNITS FEES UNITS FEES
Water Heater
I;V2 Size •� '/
Water Closets Materia;
Bath Tubs To Curb
Showers 11,V To Prop. Line
Lavatories To Existing
Kitchen Sinks j Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Coinb. Sink c Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers size/"
Restaurant Sinks Material
San .Traps TOTAL FEES
Urinals Fixture Fee
Area Drains Main Drain Fee t
Water Leaders Storm Drain Fee
Sprinkler Valves Water Sys. Fee At9p
Permit Fee 3
TOTAL �� TOTAL FEE
RE ORD OF INS CT
Underground Rough.
.Partial Rough_
Rough. Complete.. 5K 29
—
.fain Drain 0
Final._ , �.• 1 ,���
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