51119 U Oa I STREET LOT NO.
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APPLICATION FOR PLUMBING PERMIT
i i -CITY OF CUPfiRTINO
' M Sanitary No
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oa' IJ �- 196_ Permit No S
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ca is {fie to the City of Cupertino for a permit to install plumbing
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p�y+ nd,ifix�is�tlJ��(I�e reverse side hereof, and agrees to install said prices
> and/or'fixtures m actor ante wI h the provisions of the Plumbing Code of the City of
a w Cupertino, and all oth Jlaws applicable the eto.
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0 w Use of Premises
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Oa Owner�r� /y�l`. 7.'Wl ���/`/��'•�ddress�o9lJL �.�ytP.9n�
J z y��: /i(JI ��U/�//I'!�"� Address ��'j'22. .Si.C/�F_.i�ifi'n
O CONTRACTOR, AGENT
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u s ate License .2 '-tQ 2-
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Approved_
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PLUMBING INSPECTOR
FIXTURES NUMBER MAIN DRAIN
UNITSI FEES I UNITS FEES
Water Ileater I Size
Water Closet Material
Bath Tub I 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 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
Area Drain I Main Drain Fee
Water Leader Storm Drain Fee
Sprinkler Valve Water Sys.Fee
Relief Valve Gas Fee
Vac Breaker
Skimmer
Filter
Permit Fee O�
Total Total Fee U"�