NO PERMIT NUMBER (3) /0 70O I yd'!;y
NO. STREET
APPLI O IN PERMIT
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w ¢ OCT 11068
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� Application is hereby IR d t e mfor a permit to install plumbing
o 1- pipes and/or fixtures listed on the reverse /sisdeh ��and agreesto install Id pricesr and/or fixtures in accordance with the prothe Plumbin ode of CitywCupertino, and all other Taws applicable t
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LL Use of Premises
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3 Owner'o. Z? �SSoC-;A7/=) Address T��
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O CONTRACTOR, AGENT G e�
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u s State License —74 f4E-3 Approve
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—0 PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITS FEES UNIT FEES
Water Heater Size
Water Closet Material
Bath Tub To Curb
Shower To Prop. Line
Lavatories To Existing
Kitchen ink Not Conn.
Dish Washer Sewer Box
Waste Disposal
Wash Tray STORM DRAINAGE
Washing Machine Size
Water Softener Material
Bar Sink To Main Drain
Comb.Sink R Tray To Curb
Dental Unit
Drinking Fountain
Floor Drain WATER SYSTEM
Hopper Size
Restaurant Sink Material
Sand Trap TO'T'AL FEES
Urinal Fixture Fee
Area Drain Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee
Total Total Fee