NO PERMIT NUMBER (3) No. Street Lot No.'I'
o —
`n' 45 �i.
APP CP,TIODPFOR P�f1B NGI ERMIT
vE CI
/OCTT3LF196$ RTeINO1
FSanitary No.
6etbber 28, 8
E Date Permit No.
3 —CUPERTINO Fee s
s 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
c laws applicable thereto.
m ^m Use of Premises Dwelling
° 0 Ditz Crane Co. 2295 De La Cruz Boulevard
o Owner Address
o ..
- By Palm Plumbing Co. �&A Sunnyvale-Saratoga Rd.
3 Contractor,Agent
d ° Phone 245-2323
186579 WILLI,%.A U.
— State License Approved
X Plumbing Inspector
FIXTURES NUMBER MAIN DRAIN
Units I Fees i I Units Fees
Water Heater / Size
Water Close[ Material
Bath Tub To Curb
Shower 10 To Prop. Line v
Lavatories To Existing
Kitchen Sink Not Conn.
Dish Washer
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine / Size
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 Trap TOTAL FEES
Urinal Fixture Fee li
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys. Fee /S
Vac Breaker
Skimmer
Filter
Permit Fee oZ
Total / % Total Fee (p