51167.3'Ae. — I Street
ek A � APPLICA NG PERMIT
` CITTY OF CUPER I O
Sanitary No.
Lot No.
Date A, / s, 19] / Permit No.jo/n
Fee $tea
Application is hereby made to the City of Cupertino for a permit to install plumbing 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 Cupertino, and all other
laws applicable thereto.
Use of Premises( ?V'r 1 p
002
Owner /fit S//���o'g4ySEN Address 2219 0 9 lockox
ByL FE r..4jf P tce A • Address 1 10 14N HA/T INIO
Contractor, Ag nt
Phone Z 7d lf- 7 tr7//
State License Approved _
Plumbing Inspector /
FIXTURES NUMBER
Units Fees
Water Heater
Water Closet
Bath Tub
Shower
Lavatories
Kitche ink
Dish Washer
Waste Disposal
Wash Tra
Wash" Machine
Water Softener
Bar Sink
Comb.Sink & Tray
Dental Unit
Drinking Fountain
Floor Drain
Hopper
Restaurant Sink
Sand Trap
Urinal
Area Drain
Water Leader
Sprinkler System
Vac Breaker
Skimmer
Filter
Total
MAIN DRAIN
Units Fees
Size
Material
To Curb
To Prop. Line
To Existing
Not Conn.
STORM DRAINAGE
Size
Material
To Main Drain
To Curb
WATER SYSTEM
Size
Material
TOTAL FEES
Fixture Fee
Main Drain Fee
Storm Drain Fee
Water Sys. Fee
Gas Fec,
i
Permit Fee
Total Fee a SID