51187 (2)No. Street Lot No.
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E CI'T'YOFCUPERTI d0 30 1968 ifury No.
E Date /U ' 2 `1 —11961 Permit No. .S%i,1` 7
0 CITY OF CUPERTINO Fee O -S °
.'c 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.
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State License 249299 Approve,4
TJ 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
Waste Disposal
Wash Tra
STORM DRAINAGE
Washin 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
Sand TrapFEES
Urinal
Area Drain
MFixtureFee
eWater
Leader
eeSprinkler
System
Relief Valve 11
Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee J
Total
Total Fee