NO PERMIT NUMBER LOT NO.
NO. STREET
APPLICATION1rF,jO,R � NG PERMIT
" < ,arc Wrl 11
_ _ j" "
i M � " Svutar ; No.
3 a s temter;� I S EPA 3 1968
Date 19As Permit No
U � Fee $ =C,S�
° Application is hereby madel fo the�City o .jCupeiu o��fo£ a permit to install plumbing
the reverse side hereof, and agrees to install said prices
o pipes and/or fixtures listed on
r and/or fixtures in accordance with the provisions of the Plumbing Code of the City of
a w Cupertino, and all other laws applicable thereto.
~ Use of Premises Dwelling
J
000
3 Owner Ditz Crane Co. 2295 DAA4�spruz Boulevard
of 12 34 Sunnyvale-Saratoga Bd.
J o By Palm Plumbing Company Address
CONTRACTOR, AGENT
3i= 245-2323
N
Phone
W Z
R R 186579
a o State License Approved
_U PLUMBING I PECI.IR '
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNITS FEES
Water Heater Size
Water Closet Ly Material
Bath Tub To Curb
Shower / To Prop. Line
Lavatories To Existing
Kitchen Sink / Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink 'ro Main Drain
Comb.Sink&Tray To Curb
Dental Unit
Drinkin Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap 'NOTAL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee l
Vac Breaker
Skimmer
Filter
Permit Fee a
Total Total Fee 4