51137 1 D 3 al�Y/e/l e, LOT NO.
NO. STREET
APPLICATION FOR PLUMBING PERMIT
Y r( ! CITY OF CUPF.RTINO
zz
x 0 Sanitary No.
3 < Date - 196— Permit No.
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w Fee 10
Application is hereby made to the City of Cupertino for a permit to install plumbing
`o a 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
a w Cupertino, and all other laws applicable thereto.
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w Use of Premises C s
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Owner a Address lD� �✓
z By - C �' Address
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0 CONTRACTOR, AGENr
- oa, Phone ��g�2/ -�0t� �
a o State Licensrf-.�6 Approved
U PLUMBING INSPECTOR
FIXTURES
UNITS FEES UNITS FEES
Water Heate Size '
Water Closets Material
Bath Tubs To Curb
Showers To Prop. Line
Lavatories To Existing
Kitchen Sinks Not Conn.
Dish Washers Sewer Boxes
Waste Disposals
Wash Trays STORM DRAINAGE
Washing Machines Size
Water Softeners Material
Bar Sinks To Main Drain
Com . Sink s Trays To Curb
Dental Units
Drinking Fountains
Floor Drains WATER SYSTEM
Hoppers Size
Restaurant Sinks Material
Sand Traps TOTAL FEES
Urinals Fixture Fee
Area Drains MainDrain Pee
Yrs-ater Leaders Storm Drain Fee
Sprinkler Valves Water Sys. Fee
Permit Fee
TOTAL TOTAL FEE
RECORD OF INSPECTION
Underground Rough...
Partial Rough..
Rough. Complete-
Main Drain
Final...