NO PERMIT NUMBER c No. SI treet Lot No,-4d
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a APPLICATIONtFO WB1 PERMIT
1CITY EItTIO
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Y Date October 28, 1968 X31 1368 �tl ,permit No.
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0 (� Fee Sa6'-S'd
Application is hereby made to the City`6f upet p ora- unit to install Plumbing pipes
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and/or fixtures listed on the reverse side hereof,and agreed 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.
i
n U Use of Premises Dwelling
oDitz Crane Co. 2295 De La Cruz Boulevard
Owner Address
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h By Palm Plumbing Company ,MASSunnyvale-Daratoga Rd.
3 sem. Contractor,Agent
Phone
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0 245-2323
State License 186579 Approved �'a � v
Plumbing Inspector
FIXTURES INUMBER I MAIN DRAIN
Units Fees Units Fees
Water Heater f Size
Water Closet --�il Material
Bath Tub / To Curb
Shower / To ProD. Line
Lavatories To Existing
Kitchen Sink / Not Conn
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washin Machine Size
Relief Valve 11 Gas Fee Irw
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
Sand TrapTOTAL FEES
Urinal Fixture Fee % I"
Area Drain Main Drain Fee .47/
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee
Vac Breaker
Skimmer
Filter
Permit Fee c1
Total / Total Fee -2 ,