51046 / D lY O <n 1 g LOT NO.
NO. STREET
1 VI^N FOR PLUMBING PERMIT
L Y OF CUPERTINO
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oa DatTe —�(�I'—[�7 196— Permit No.
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Application a e the Cit}' of Cupertino for a Perms to install Plumbing
o 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
a w Cupertino, and all other laws applicable thereto.
0LL , Use of Premises
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By Al y mr 3/l✓Q,css/2/7 &-LL- A U r
3 o CONTRACCTOR, AGENT
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O F State License /Q 2 7 S77 Approved'-- /
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— PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink 8 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 Storrs Drain Fee
Sprinkler Valve WaterSys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Ij Total Fee