100248 /V ?55 S - 50,e ry VALe ;An 47d j r.
No. Street / -Lot No.
o
d APPLICATION FOR PLUMBING PERMIT
I
E Cny Of CRE"M CITY OF CUPERTINO
E
H MAY 3 1971 Sanitary No.
E Doo �) 1901L Permit No.)O0, `-4p
y r
° - Fee S •O Q
3
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
o in accordance with the provisions of the Plumbing Code of the City of Cupertino,and all other
'c laws applicable thereto.
i0 `o
v Y S' j p tr
A M Use of Premises /• Cl1(j h+ Fa d
o U - 5,.�Fy vA a .SM17bG4
° Owner P1 /'1 r ��t A'RV Address jt'15S
o m
o rn By Qe A-V;,-,A PIP // r v 4 AddressloLyQ CRA/y e
3 Contractor,Agent ^
° Phone '9 i Z - 7 /f `/ Q
State License Approve
Plumbing Inspector
V
FIXTURES NUMBER MAIN DRAIN
Units Fees Units Fees
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Pro . 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 `3;c0
Area Drain Main Drain Fee
Water Leader Storm Drain Fee —
Sprinkler System Water Sys.Fee
Relief Valve Cas Fee
Vac Breaker
Skimmer
Filter
,fZ0 At S;A,K
Permit Fee 2, 00
Total 3,00 Total Fee ,00