NO PERMIT NUMBER 2A/3 O (i foam
No. Street Lot No.
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APPL10 I - BI P IT
E 3 `" CITY OF CUPERTINO
n 10CT 30 1968
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'''��'ggg Sanitary No.
Y Date �Q _ wi rib CUPERTINO Permit No. Q
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3 1 Fee 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
laws applicable thereto.
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ro Use of Premises
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' ° Owner /S 7 a q�/J2 s
Address /,3� �J/� r:KV?o
By /U�LI//1(9/I�(.i � l�OL Addres ,\rC61-717i teCllq`
3 ,C/o actor,Agent
y 0 Phone 'I'7Sr1S� --��
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— State License /570—I/1 Approv 404 goo
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 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 1 7
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler System Water Sys.Fee
Vac Breaker
Skimmer
Filter
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Permit Fee �;2, d a
Total -r Total Fee