51046 (2) I4�-(/-O-'I/ !C W LOT NO.
NO. STREET
�TPLICAXIjl�N FOR PLUMBING PERMIT
i i ,� OP CUPERTINO
p �� Sanitary No.
W EP g 1967 196_ Penna No
j e
� _
0 a llate
3 4 1�g-r� Fee $ 7�
0 A(pp' c'1tioQ hcCgk)', RTtE rt)3 City of Cupertino for a permit to install Plumbing
o r pipes and/or fixtures listec�d 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 laws applicable thereto.
w x �
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W Use of Premises
00
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3 Owner cni✓sr.�.o e% Address
pJ
By Y11s'-9�'a ,E`3.�� Address lutea e�c � C�ao't
3 0 CONTRACTOR, AGENT
N
Phone 296e�5��9 �11/Y1l1 G �it�.
W 2
Q n WILLIAM D. 8ENEVICH
a o State License Approved
`� -U PLUMBING INSPECTOR V1
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&Tray To Curb -
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee 6 Cr
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve I Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee d
Total Total Fee o